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SKIN DISEASES: 



THEIR 



DESCRIPTION, PATHOLOGY, DIAGNOSIS AND 
TREATMENT. 



SKIN DISEASES 



THEIR 



DESCRIPTION, PATHOLOGY, DIAGNOSIS, 
AND TREATMENT. 



BY 

TILBUET FOX, M.D. Lokd., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIAN'S OF LOXDOS; 

PHYSICIAN TO THE DEPARTMENT FOR SEIX DISEASES L\ OITERSTTY COLLEGE HOSPITAL ; 

FELLOW OF rXTYERSITY COLLEGE. 



SECOND AMERICAN 
FR02I THIRD LONDON EDITION, RE-WRITTEN AND ENLARGED. 



WITH A CUTANEOUS PHARMACOPOEIA, A CLOSSARIAL INDEX 
AND SIXTY-SEVEN ADDITIONAL ILLUSTRATIONS. 



NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 

1873. 






iy\\ 




Entered according to Act of Congress, in the year 1873, by 

WILLIAM WOOD & COMPANY, 

In the Office of the Librarian of Congress, at Washington, D. C. 



Poole & Haclatjcbxan, 

printers and bookbinders, 

205-213 East Twelfth St., 

NEW YORK. 



DEDICATION. 



TO 

EKASMUS WILSON, F.E.S., 

PROFESSOR OF DERMATOLOGY IN THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, 

$l)is Volume is IDebicatelr, 

WITH A FEELING OF ADMIRATION FOR THE TALENTS AND THE WORK, WHICH 

HAVE RIGHTFULLY EARNED HIM 

A PROUD POSITION, 

AS THE ACKNOY/LEDGED HEAD OF DERMATOLOGISTS : 

AND FOR THE FOSTERING CARE WHICH HE HAS EXHIBITED TOWARDS DERMATOLOGY 

FOR NEARLY HALF A CENTURY ; 

BUT NOT LESS IN ACKNOWLEDGMENT OF MANY PERSONAL ACTS OF 

KINDNESS AND FRIENDSHIP, 

BY THE AUTHOR. 



PREFACE 



TO 



THE THIRD EDITION 



The second edition of this work, which was a very large one, is 
now exhausted, with the exception of a few copies ; and whilst I 
am called upon to furnish the English reader with a third, a new 
American edition is required." The work is also about to be issued 
as a text-book in Italy. These circumstances may, I think, be 
fairly regarded as conclusive evidence of the practical character 
and usefulness of the book, and I have redoubled my efforts to 
improve it. In fact, it is practically a new one. It has left my 
hands rewritten, and with the matter recast, rearranged, and re- 
illustrated in such manner that I am emboldened to hope I have 
at length produced a work which may be looked upon as containing 
the latest, fullest, and best practical information of any book on 
the subject of skin diseases. 

I have written the book in the first instance to meet the wants of 
the practitioner in his daily dealings with disease ; at the same time 
I have not forgotten what the student requires in his preparation 
for examinations. 

The pathological sections have been particularly amplified, and 
I am greatly indebted to Dr. Neumann, of Vienna, for allowing 
me to make such free use of certain of his illustrations, as well as 
to others whose names are printed in the text. 



Vlll PREFACE. 

I clo not specify any particular pages of new matter, for the 
simple reason that there is not a page without it. The reader will 
find two forms of disease described in detail for the first time 
nnder the terms fibroma fungoides and dysidrosis. 

I believe that I have simplified matters very materially in regard 
to the varieties and nomenclature of cutaneous diseases. 

Finally, I cannot but express my gratification at the philosophic 
spirit in which dermatology is being vigorously studied, not only 
by such men as Neumann, Moritz Kohn, Auspitz, and others, in 
Germany; Faye, of Christiania, and Nystrom, of Stockholm ; but 
also by a number of American confreres — Taylor, Henry, Haight, 
Duhring, Wigglesworth, and others, whom I am able to claim as 
personal friends. I think the profession in general, and derma- 
tology in particular in America, owes much to Dr. Henry for the 
excellent Journal of Dermatology which he originated and so ably 
conducts; and I cannot forbear at the same time acknowledging 
how much I am personally indebted to him as the editor of the 
American edition of my work. 

14 Haelky Street, 

Cavendish Square, 
Jan. 1st, 1873. 



PKEFACE 



SECOND AMEKICAN EDITION, 



About two years ago I prepared, with the sanction of the author, 
the first American Edition of his excellent work on skin diseases. 
I stated at the time that I knew of no work on Dermatology in our 
language that combined so completely the results of a thorough 
knowledge of the pathology of skin diseases, such sound clinical 
observation, and so rational a system in the application of thera- 
peutics. In the new edition the author more than confirms all that 
I then stated. It is, I think, the very best work on skin diseases 
ever offered to the American student and practitioner of medicine. 

The estimation in which the work has been held in this country 
is sufficiently attested in the entire sale of the last American edi- 
tion, and the general praise accorded to it by those skilled in Der- 
matology. 

In this edition, which is printed from the latest London edition, 
I have had no opportunity of doing more than revise the work as 
it passed through the press — so completely has the author antici- 
pated all the wants and essentials of a complete work on skin dis- 
eases. 

M. H. HENRY. 

157 West Thtrty-foukth Street, 
New York, June, 1873. 



CONTENTS 



CHAP. PAGE 

I. INTRODUCTORY REMARKS — THE MODE OF STUDYING SKIN DISEASE. 1 
IL THE ANATOMY OP THE SKIN AND ANATOMICAL CONSIDERATIONS — 

GENERAL REMARKS IN RELATION TO HISTOLOGICAL CHANGES... 13 
III. GENERAL PATHOLOGY OF THE SKIN — ELEMENTARY LESIONS — SEC- 
ONDARY CHANGES 27 

FV. ETIOLOGY— BLOOD TISSUE AND NERVE CHANGES — INFLUENCE OF 
SEX, AGE, OCCUPATION, FLANNEL, SCRATCHING — CONDITIONS 

THAT DETERMINE THE LOCAL DEVELOPMENT OF DISEASE 49 

V. CLASSIFICATION 56 

VI. GENERAL DIAGNOSIS — PROGNOSIS AND PRINCIPLES OF TREATMENT. 59 

VII. ERUPTIONS OF ACUTE SPECIFIC DISEASES 80 

VIII. ERYTHEMATOUS DISEASES 104 

IX. PLASTIC INFLAMMATION, OR LICHEN ,..-.. 137 

X. CATARRHAL INFLAMMATION, OR ECZEMA . 162 

XI. BULLOUS DISEASES 199 

XII. SUPPURATIVE INFLAMMATION OF PUSTULAR DISEASES 223 

XIII. SQUAMOUS INFLAMMATION 252 

XIV. DIATHETIC DISEASES 275 

XV. HYPERTROPHIC AND ATROPHIC AFFECTIONS. 330 

XVI. NEOPLASMATA, OR NEW FORMATIONS. • 369 

XVII. HAEMORRHAGES 392 

XVin. NEUROSES OF THE SKIN 395 

XIX. CHROMATOGENOUS DISEASES— PIGMENTARY 399 

XX. PARASITIC DISEASES 405 

XXI. DISORDERS OF THE GLANDS 475 

FORMULARY . 505 

GLOSSARIAL INDEX 521 



ILLUSTRATIONS, 



FIG. PAGB 

1. Section showing the general structure of healthy skin , . , 14. 

2. Spindle-shaped, or " migrating " cells (Pagenstecher) ....... 16 

3. Papillse, vascular and nervous, of the skin (Biesiadecki) 18 

4. The hair follicle, as normally composed (Biesiadecki) 20 

5. Section of a sweat gland (Biesiadecki) 22 

6. Section of a nail at its bed (Biesiadecki) 23 

7. Section of a bulla in erysipelas (Haight) 34 

8. Section of a variolous pustule (Auspitz) , 82 

9. Section of the skin in erysipelas (Neumann) 92 

10. Section showing the morbid changes in lichen ruber (Neumann) 147 

11. Section showing changes in the hair follicle in lichen ruber 148 

12. Section of skin in lichen scrofulosorum (Kohn) 152 

13. Section of skin in prurigo (Neumann) 158 

14. An eczema papule, its minute characters (after Biesiadecki) 171 

15. Section of skin in chronic eczema (Rindfleisch) 172 

16. Section of skin in chronic eczema (Neumann) 173 

17. Section of skin in herpes zoster (Haight) 205 

18. Section of skin about nerve trunks in ditto (Haight) 206 

19. The early aspect of malignant pustule 238 

20. Representation of Delhi boil on face 243 

21. Representation of Delhi boil on hand 243 

22. Bodies found in discharge in Delhi sore (Smith) 244 

23. New growth in skin in Delhi sore (Fleming) 244 

24. Altered hair bulb in Delhi sore (Fleming) 244 

25. Altered hairs in Delhi sore (Fleming) t 245 

26. Section of skin in psoriasis (Neurnann) 262 

27. Rupia of the face 287 

28. Dactylitis syphilitica of the toe (Taylor) 299 

29. Results of dactylitis on the hand (Taylor) 299 

30. Dactylitis of the finger (Taylor) 299 

31. Syphilitic tissue, its microscopic characters (Auspitz) 302 

32. Syphilitic cicatrization, its microscopic characters (Auspitz) 303 

33. An eastern leper 313 

34. Head of leper, showing tubercles on face 313 

35. A leprous tubercle, its minute characters (Neumann) 318 

36. Leprous cell tissue (Virchow) 319 

37. Section of icbthyotic skin (Kohn) 338 

38. Section of skin in scleroderma 343 



XIV ILLUSTRATIONS. 



39. Keloid tumour, representation of , , , 348 

40. Minute structure of keloid growth (Neumann). , 350 

41 . Representation of fibroma , 352 

42. Representation of fibroma in the fingers 353 

43. Fibroma fungoides in a woman's face .' 354 

44. Fibroma, general minute characters of (Fagge) 356 

45. Fibroma, microscopic characters of 357 

46 to 48. Ainhum : microscopic characters of (Silva Lima) 363 

49. Section of skin in senile atrophy (Neumann) 367 

50. Gland changes in skin in senile atrophy (Neumann) 368 

51. Lupus tubercle, section of (Auspitz) 373 

52. Changes in lupus erythematodes (Neumann) 380" 

53. Cancer, general structure of (Rindfleisch) 384 

54. Cancer, general structure of (after Koster) 385 

55. Cancer cylinders, structure of (after Koster) 386 

56. Rodent cancer, cell growth in 390 

57. Leucoderma 401 

58 to 61. Pediculus capitis, pediculus pubis, pediculus corporis, pediculus ves- 

timenti (structure of mouth of pediculus) 410 to 413 

62. Acarian furrow (Neumann) 417 

63 & 64. Itch Insects '. 420, 424 

65. Stromal form of fungus 427 

66. Achorion Schonleinii (f avus fungus) 430 

67. Tinea tonsurans, diseased hair in 434 

68 & 69. The trichophyton tonsurans 435 

70. Mycelium in root of hair 440 

71 & 72. Fungus elements in the dust from the air 443-4 

73. Fungus in parasitic eczema 449 

74. Fungus of eczema marginatum 451 

75. Fungus in Burmese ringworm 453 

76. Diseased hair in tinea tonsurans of the horse 454 

77. Fungus in scales from tinea circinata transmitted to man from horse 455 

78 & 79. Diseased hairs from parasitic sycosis 458 

80. Hair split up by fungus 459 

81 & 82. Hairs from tinea decalvans 460-1 

83. Fungus of tinea versicolor 463 

84. Fungus of onychomycosis 467 

85. Madura foot, representation of 469 

86. Chionyphe Carteri (after Carter) 470 

87 & 88. Fish roe-like bodies discharged from fungus foot 471 

89 & 90. Chionyphe Carteri, more highly magnified 471 

91. Sudamina, microscopic structure of vesicle in (Haight) 483 

92. Acarus f olliculorum 490 

93. Contents of molluscum contagiosum, minute characters (Fagge) 492 



DISEASES OF THE SKIN. 



CHAPTER I. 

I. INTRODUCTORY REMARKS. 

In former editions of this work I devoted some space to comments 
npon the importance of a careful study, on the part of the student 
and the practitioner, of diseases of the skin. Such a step, in the face 
of the present nourishing state of dermatology, and the increasing 
attention paid to it in all directions and in every country, is 
a wholly unnecessary one on my part. But I cannot forego the 
observation that a reputation is easily made, in diagnosing and 
treating cutaneous ailments correctly ; and for the manifest reason 
that the course of these diseases, the changes which they undergo, 
and the effect of remedies upon them, are peculiarly open to the ac- 
curate observation of patients. Patients can speedily judge whether 
the physician is likely to do them good or harm. The inveterac}' 
and disfiguring character of skin diseases, moreover, greatly affect 
the personal comfort and vanity of men and women, so that relief . 
is estimated at a comparatively high standard. The only safety to 
the practitioner lies in his having such a knowledge of the nature 
of cutaneous mischiefs as will enable him at the outset to make a 
good diagnosis, to give a reliable prognosis, and to prescribe the 
remedy which at least does not intensify if it does not alleviate 
the symptoms of which complaint is made, inasmuch as the 
patient can observe for himself so readily the real effect of remedies 
upon his disorder. What not to do — what to avoid — in treating 
skin diseases, which pre-supposes a correct knowledge of their 
general course and behaviour, is an important lesson to learn in 
regard to them. In this respect the management of cutaneous 
diseases has minor peculiarities of its own. But he who would be a 
successful dermatologist, I have always held, and hold more strongly 
than ever, must also be a proficient in the principles of general 
medicine. The successful study of skin disease necessitates a 
knowledge on the part of the student, whoever he may be, of 
diseases in general — and he alone can treat cutaneous ailments 
satisfactorily who is master of the details of general therapeutics. 
The same disease, as it occurs in persons of different diathetic 
tendencies, requires to be handled in a somewhat varying manner. 



2 THE MODE OF STUDYING SKIN DISEASES. 

Eczema, for instance, in an old and gouty, a young and pallid, or a 
scrofulous subject, requires not the same, but modified treatment 
to meet the circumstances of each particular case. The rank spe- 
cialist or mere empiric would diagnose the eczema, pay no heed to 
the diathesis, and employ a therapeute, which he has stereotyped, 
as suited to eczema, under all conditions. The philosophic prac- 
titioner, bringing into use his knowledge of medicine in general, 
would be careful to take advantage of known specifics ; but he 
would treat any constitutional condition which tended to aggravate 
the main disease, or to prevent reparative action; and he would 
rectify errors of function or departures from healthy action in 
organs and parts which, bearing relation by interdependence of 
function, thereby influence for evil the already diseased skin. The 
removal of a stomach, a kidney, a uterine, a liver derangement, a 
cause of general debility, or one that checks elimination, or that 
in other ways interferes with the clue play of the vis medicatrix 
naturw, gives a patient a much better chance of getting well under 
treatment intended to cure a co-existing skin disease. Therefore, 
to be a successful dermatologist, it is necessary to be a well- 
informed physician. 

The dermatologist has hitherto practically ignored this fact in the 
pathology to which he has pinned his faith, and the therapeutics he 
has adopted. I have no hesitation in saying that the best prepara- 
tion for the study of diseases of the skin, is a good grounding in 
general medicine, at the bedside and in the dead-house. I also 
think dermatology has been as much retarded by having been 
viewed too much from the surgical, as it will be advanced from 
considering it in the future, from the purely medical point of view 
in connexion with recent advances in pathological observation. 

II. THE MODE OF STUDYING SKIN DISEASES. 

I will venture to lay down certain guides, rules, or general 
principles, which should be observed in entering upon the study 
of diseases of the skin; and I will give them categorically. I 
suppose of course that no one comes to the task without a fair 
knowledge of general medicine. 

1st. — In the first place, the observer should always strip his pa- 
tient so that the disease may be exposed to the fullest extent com- 
patible with a due regard to the proper feelings and sensitiveness 
of the individual. To be satisfied with seeing a bit of a patch of 
disease in this spot, or just a spot or two there where the malady 
is most marked even, is often to run great risk of arriving at an 
erroneous diagnosis, if not to actually make one, certainly to miss 
the recognition of transitional stages, which are of the utmost 
importance in determining the general character and often the 
exact nature of a disease. 

2nd. — It is of much importance that mere stages of diseases should 



THE MODE OF STUDYING SETN DISEASES. 6 

be regarded as stages and nothing else. Diseases must be dealt 
with in their entireties. Where the whole of a disease is made 
up in any particular instance of certain stages, in estimating the 
nature and characteristics of that disease, one stage must not be 
regarded in particular — be thrust into undue prominence — at 
the expense of others. The several stages together constitute the 
disease. I may illustrate what I mean by reference to small-pox, 
eczema, and ringworm. The former consists of an eruption of an 
inflammatory kind which has its papular, vesicular, pustular, crust- 
ing, and other stages, and in describing small-pox it is usual to 
say that it consists of certain stages, characterized by certain 
elementary lesions. The very mention of the word small-pox 
suggests to the mind the occurrence of certain transitional stages, 
and the clescriber would offend against custom and scientific rule 
if he broke up the disease into papular small-pox, vesicular small- 
pox, pustular small-pox — if he made stages, varieties. But this is 
exactly what some do with regard to eczema ; writers describe 
erythematous, papular, vesicular, pustular, squamous, dry and 
moist eczema, and so on ; whereas, eczema should be regarded as 
consisting of certain stages, and every case of eczema (except 
when abortive) as possessing these stages in a greater or less 
degree. It is quite right to speak of the papular stage, the vesi- 
cular stage, and so on in small-pox. The same rule ought to be 
observed in the case of eczema. It may be said, Why be so 
particular ? For the very reason that the confusion of stage and 
variety leads to errors of diagnosis. It leads the observer to 
regard merely secondary as primary conditions, or even varieties, 
and to study the disease in a piecemeal manner. Nothing is more 
common than for the observer to regard ordinary cases of eczema 
in the squamous stage as a special variety of eczema, and to con- 
fuse it with psoriasis, because of losing sight of its earlier phases. 

It is as wrong to describe an eczema squamosum as a distinct 
variety, as to describe the pustular stage of small-pox, or the stage 
of grey hepatization in pneumonia, or the stage of contraction of the 
liver or kidney in cirrhosis, as separate varieties of disease, and 
apart from preceding stages. There are varieties of eczema, but 
they are based upon the general features, constitutional and local, 
of classes of cases taken as a whole, stages included. 

3rd. — A clear distinction should be drawn between essentials 
and accidentals. For instance, the essence of scabies is the acarus 
in its burrow. All else that follows — the follicular irritation, im- 
properly called lichen, the ecthyma, the urticaria, which may 
occur in many different diseased states of the skin — is accidental, 
and due to the irritation and the scratching practised. Yet these 
secondary occurrences are described as essential parts of the 
disease. 1 hold that the ordinary division of scabies into papular, 
vesicular, and pustular scabies is thoroughly wrong in every way 
because it is based upon the variations of, and the appearances 



4 THE MODE OF STUDYING SKIN DISEASES. 

presented by, mere phases, not of the essentials of the disease, 
but accidental conditions, the consequence of irritation. So I 
think scabies should be described as a disease produced by the 
burrowing of the acarus, whose characteristic lesion is a furrow 
possessed of certain features, and at the end of which is the em- 
bedded acarus ; the irritation set up and the scratching practised 
giving rise to such and such accidental contingencies. This 
simplifies matters, and gives due pre-eminence to what is the sure 
diagnostic guide to the disease. Peculiarities in the distribution 
of accidentals suggest no doubt the nature of the cause and the 
seat of its operation, as for instance the forearms and penis in 
adults, the buttocks and feet in children in scabies. Another ex- 
ample is afforded by the interpretation put upon oedema. ISTow oedema 
arises from various causes, especially retarded circulation ; hence it 
is seen in connection with varicose veins of the leg, occurring with 
eczema of that part, but no one is thereby warranted in making a new 
variet}' of disease, E. oedematosum, any more than in the case of ery- 
sipelas oedematosum, because oedema is a prominent feature in some 
cases of the latter. (Edema is a mere accident. JSTo doubt such 
accidents supply a guide to complicating conditions, but that is all. 

4th. — It should be a point with the dermatological student to 
make as little as possible of mere superficial appearances and 
changes, because these are brought about as the result of, and are 
indeed often secondary to, more important and primary changes in 
the deeper parts. This point will be abundantly illustrated in 
dealing with elementary lesions. 

5th. — It is important to pay special attention, as far as 
possible, to the primary anatomical seat of the disease. What the 
primary seats of individual diseases are so far as regards cutis, 
cuticle, follicles, and the like, I shall discuss in another place in 
speaking of elementary lesions and the individual diseases them- 
selves. I only now wish to make one or two general comments on 
the matter, so far as the intimate tissues — vessel, blood, cell,* and 
nerve are concerned. 

In the first place having, in regard of any diseased conditions 
present, decided what are essential and what accidental (this has 
been referred to already), the observer has then to determine the 
real seat of the primary mischief. ISfow, theoretically, diseases of 
the skin must arise in disorder, in the first instance, of either (a) 
the blood, (b) the tissues, intimately and anatomically considered 
as cells or fibres, or (c) nerves, or (d) the vessels — blood or 
lymphatic. 

By and by, it will no doubt be practicable to form a classification 
upon this basis — an anatomico-pathological one ; but at present, ob- 
servers have only approximately determined the primary seat of 
disease in a few cases. It has been the fashion to ascribe every 
disease of the skin to " some condition of the blood," but we now 
know that this is a very erroneous supposition, and for my own 



THE MODE OF STUDYING SKIN DISEASES. 

part I believe that the blood may be remarkably passive in regard 
of many cutaneous diseases. Familiar illustrations of skin erup- 
tions due to blood alterations as their essential cause, are to be 
found in the eruptions of acute specific diseases, of syphilis, me- 
dicinal rashes, &c. But there is reason to think that more 
skin diseases than have been hitherto imagined originate in a mis- 
behaviour or perverted action primarily of the tissues themselves, 
especially their cell elements. As for instance, epithelioma and its 
congener rodent ulcer, lupus, psoriasis very likely, as well as warty 
growths, keloid, fibroma, and so on. In psoriasis there is no 
evidence that the disease is the result of a special blood alteration, 
nor is the amount of cell change in any way necessarily related to 
the amount of hyperemia, but rather the reverse oftentimes ; and 
1 see no difficulty in accounting for the disease by a perverted 
growth of the rete cells, originating as an independent phenomenon. 
This power of independent nutritive action is seen in the migrated 
cancer cell, in the growth of the piece of transplanted cuticle in 
skin grafting, in amoebiform changes in cells, &c. 

It is to be observed however that those diseases which are not ac- 
tually originated, are oftentimes very materially w^^^cW and modi- 
fied by blood alterations. The consideration, however, as to whether 
a disease originates in the tissues or the blood, or other part, bears 
directly on the treatment. If psoriasis, for instance, be a blood 
disease, the operation of our remedies must be directed against 
the blood condition. But if the disease originate in the tissues, 
our remedies must be mainly such as will tend to check the pro- 
liferation of the cell elements, and local applications will probably 
be the most important. As the knowledge of physic increases, 
this idea will be more clearly acted upon. 

Alreadj' — to refer particularly to tissue life — the pathologist 
attaches importance to the part which the cell elements play in skin 
diseases. In the commonest affections, as eczema, zona, and the 
like, the researches of Virehow, Eecklinghausen, Neumann, Derby, 
Auspitz, Biesiadecki, Koster, and others, have shown that the 
connective-tissue corpuscles primarily undergo great and peculiar 
changes. In the case of cancer, much is being done to clear up 
the nature of the cell changes, and no one can doubt that the 
disease begins in the tissues. 

There is this distinction to be made here, viz. — that whereas 
in some of the more common diseases, as eczema, the cell changes 
are the result of nerve paresis, in others, as in cancer, there is no 
evidence that they are more than the result of alteration or per- 
version of the " directive agency " or " formative capacity," as 
physiologists term it, of the cells themselves. I confess that I 
incline to the view that in psoriasis, the primary change begins in 
the cells, in a misbehaviour of the cell elements themselves. 

But further, diseases likewise originate in nerve-disorder, and 
such diseases constitute a very important and an increasing class. 



6 THE MODE OF STUDYING SEEN DISEASES. 

The trophic nerves in some cases seem specially affected, and in 
others the sympathetic or vaso-motor nerves. At present there 
exists only the promise of important results from research, for the 
physiologist aids the dermatologist but slightly in his endeavour 
to unravel the causes of cutaneous neuroses, since he has not as 
yet accurately determined the part which the cerebro-spinal nerves 
and the sympathetic respectively play in healthy nutrition. The 
nerves are unquestionably not only concerned in controlling the 
calibre of the vessels, contraction being induced by the cerebro- 
spinal, and dilatation by the operation of the sympathetic in 
negativing or restraining the action, or throwing into a state of 
rest the cerebro-spinal nerves — but lively cell proliferation and 
metamorphosis, according to the researches of Pniiger, Heidenhain, 
and others, may be induced by the irritation of the trunks of nerves, 
and certainly glandular secretion is increased thereby. 

A good paper, touching this subject, was published by Dr. 
Rutherford, in one of the recent numbers of the Journal of Anatomy. 
He says, that " whatever be the action of the visa f route in pro- 
ducing congestion of a part, the chief cause is the action of the 
tissues upon their vaso-inhibitory nerves, whereby the vessels are 
partially or completely paralysed ; " an explanation that accounts 
for the coincident or secondary hypersemia observed in connexion 
with diseases in which the alteration of the tissues themselves is 
primary, as in psoriasis for example, as I think. See also Dr. 
Meryon {Proceed. Med. Chir. Soc, Jan. 14, 1870). 

Now to apply these doctrines to the explanation of cutaneous 
changes and the determination of the primary anatomical seat of 
disease. Theoretically the trophic nerves, if there be such, may 
be disturbed, and as the result peculiar changes in the cell-ele- 
ments of the skin occur ; but these changes react upon the sym- 
pathetic ganglia through the sensory filaments with consequent 
vaso-motor changes; or an impression made on the skin by any 
kind of irritant may at once derange the ganglionic action through 
the agency of the sensory fibres, and cell and vaso-motor distur- 
bances ensue. But on the other hand, the inhibitory action of the 
sympathetic may be excited, and then the consequence will be 
hyperemia as a primary condition, to be followed by the con- 
sequences of hypersemia under certain circumstances. I believe 
these are truths of very great importance and to be more decidedly 
recognised by dermatologists. If I did not think so, I would not 
allude to them. 

It is important to note, however, that the evidence most 
recently derived from experimental section of the sympathetic 
nerve, seems to prove that something more than mere active or 
passive dilatation of the vessels is required to induce actual in- 
flammation, that is to say, hypersemia with new cell products ; foi 
it has been shown that an increased current of blood, with its 
concomitant phenomena of augmented heat, increased secretions, 



THE MODE OF STUDYING SKIN DISEASES. 7 

and more acute sensibility, may exist for months after section of 
the sympathetic, without proceeding to disease. If insufficient nou- 
rishment be present, then inflammatory changes occur, the increased 
activity of interstitial absorption leading to rapid disintegration of 
the several tissues, and destructive inflammation. Irritation of 
the nerve trunk or the ganglia, I may add, will probably excite 
inflammation as well after section of the nerve. 

In vaso-motor disturbance of course hyperemia is primary, and 
in trophic nerve mischief, if such exist, textural alteration comes 
first. But the two, tissue and vessel, may be simultaneously af- 
fected, no doubt. In pityriasis rubra for instance, it is likely that 
this is the case. 

In some cases where hyperemia of the skin following nerve 
paresis occurs, very frequently there is not a little coincident con- 
gestion of internal organs, due to a similar cause to that which 
operates to produce the hypersemic skin. Lastly, congestion of 
the skin may arise by reflex action, as in the case of erythema of 
the face, due to gastric and uterine disorders. 

So much for blood, tissue, and nerve. I must add a word about 
the lymphatic system, so far as that is concerned in the produc- 
tion of skin diseases. I do not now refer to inflammation of the 
lymphatics and its consequences, but the effect of an alteration in 
the supply of lymph to the tissues, be that produced how it may. 
Dr. Broadbent {Journal of Anatomy and Physiology, Nov. 1869) 
concludes that the lymphatics receive the spare nutrient material 
which is forced onwards by the continued exudation of fresh 
fluid from the capillaries, and finds its way along the vessels to 
the thoracic duct. The non-diffusible colloid matters which have 
traversed the delicate capillary membrane outwards under pressure, 
cannot return against pressure, and must remain in the intertex- 
tural spaces, which are no other than the commencing lymphatics. 
In the Obstetrical Transactions, some years since, 1 argued that 
this very explanation was the true one. I believe that hypertrophic 
growths of the fibro-cellular tissue may result from the non-removal 
or too abundant supply of lymph. The probability that the lym- 
phatics may be primarily concerned in the production of certain 
skin affections must be borne in mind. 

6th. — Special attention should be paid to the fact of the charac- 
ters of an eruption being permanent, or transient, or interchangeable. 
The case of lichen planus may be taken to illustrate this point. In 
it the characteristic lesion is a red flattened papule covered by the 
minutest scales. This is the sole lesion present. The papule 
never changes into a pustule or a vesicle ; but not so is it with the 
papule of eczema or variola. The tendency of a Syphilitic papule 
is to become oftentimes a pustule or tubercle, which gives place to 
an ulcer, and so on. The eruption as a whole may be again capri- 
cious, appearing and disappearing suddenly, often in the course of a 
few minutes. This feature in itself is almost diagnostic of urticaria. 



8 THE MODE OF STUDYING SKIN DISEASES. 

7th. — Those who are studying skin diseases should observe 
whether an eruption be uniform or multiform in character. Mul- 
tiformity implies (a) the co-existence of two or more diseases, in 
which case there will be present the features of the two or more 
diseases commingled ; or it implies (b) the existence (1-) if the lesions 
be inflammatory — i.e., if pustules or vesicles be present, of scabies, 
or (2) if the lesions be degenerative, if ulcers and suppurating 
tubercles, for example, be present, of syphilitic disease. The dif- 
ference between the two main classes of cases, the complicated 
disease on the one hand and scabies and syphilitic on the other, 
being, that in the former there are no transitional stages observed, 
as in purpura urticans, pemphigus pruriginosus, impetigo and 
scabies ; syphilis and scabies, &c. ; whereas in the latter class, they 
are present as between the papules, vesicles, and pustules of scabies, 
or the papules, tubercles, pustules and ulcers of syphiloderma. 
As I have before indicated, the multiformity (which by the way 
might have been referred to under the head of diagnosis) as it 
exists in scabies and syphilitic eruptions — relates in each case to 
such different kinds of eruption, and the multiformity moreover in 
complicated or co-existent diseases is seen to be due to the com- 
mingling of such distinct lesions without transitional forms, that 
the character of multiformity becomes at once a very reliable 
guide hi diagnosis ; of course, other things help, as seat, develop- 
ment, &c, but multiformity is a good rough test of syphilis, 
scabies^ or complicated diseases. 

8th. — It is wise to note certain differences, not only as to 
the general nature and character of cutaneous diseases as they 
exist in the old and young, but also in reference to the same 
disease as it occurs in the old and young. The cutaneous diseases 
of childhood are essentially distinguished from those of the adult, 
in that they are uncomplicated by organic diseases of internal 
organs, and by those more complex and profound perversions of 
nutrition which arise from over-worked or badly used organs, 
such as gout, dyspepsia, free retention of excreta in the blood, 
rheumatism, and so on. They contrast with those in the old by 
the absence of coincident degenerative changes in the body, which 
are to be the lot of the man who passes the meridian of life. The 
cutaneous diseases of children are uncomplicated in this respect, 
and speaking generally, they are the result of the misuse of 
pabulum supplied to the body, or the direct consequence of 
improper diet. The case of eczema infantile may be taken as an 
example. But there is a difference in constitutional conditions — 
the diathetic conditions in the child who suffers from skin disease 
are different from those of the adult or aged. It does not take 
any long time in the out-patients' room to see how frequently the 
subjects of skin diseases in the young are strumous, and what an 
influence this diathesis has on' the skin diseases of the young as 
contrasted with those of the middle-aged and of an age beyond the 



THE MODE OF STUDYING SKIN DISEASES. U 

latter period of life : that syphilitic affections other than those 
hereditarily transmitted are specially the privilege of the adult, and 
so on : that in the advanced in years there are not only complicating 
organic diseases of internal organs, blood alterations due to mal- 
assimilation, degenerative tissue changes such as cancer, but 
disease specially connected with decay of the nervous system, as in 
senile pruritus. But to put what I wish to enforce in a few words, 
I may say that as regards hind, the diseases of children are the 
result of mal-nutrition from deficient or bad feeding ; those of the 
adult the result of mal-assimilation ; those of the aged the result of 
degenerative changes. As regards complications, diseases of the 
young are often closely connected with the strumous diathesis espe- 
cially ; those of the adult with functional derangements of internal 
organs and mal-assimilation, such as dyspepsia, hepatic and renal 
torpor — and with, the diathetic conditions, phthisis, rheumatism, 
and the commencement of gout ; those of the aged are linked 
with nerve pareses and degenerations of the skin, as evidenced by 
increased pigmentation, atrophy of the glands, and of the nerves 
in the papillae and also with organic diseases of important internal 
organs. All this is important therapeutically. 

9th. — It is to be remembered that there is a difference in 
the conditions associated with skin diseases, as they occur in hos- 
pital and private practice. The constitution of the hospital patient 
is depraved by mal-hygiene and want of proper food, that of the 
private patient is depraved, no doubt by want of hygiene often- 
times, but also by overloading of the digestive organs, and not 
from actual want of food. But more than this ; the nervous system 
participates in the latter much more actively in helping, con- 
trolling, or modifying the existing disease ; and this as the result 
of the luxury enjoyed by the rich, and the greater mental toil 
undergone by the busy man of the middle classes, the effects 
of which, in both cases, are felt by the offspring. The old amongst 
the hospital patients show especially nervous symptoms connected 
with physical decay, and at the two extremes of life the evil con- 
sequences of uncleanliness are most marked, because there is less 
power to resist its influence — in the hospital patient. 

10th. — There are differences in the same disease as seen in 
this and other countries, as well as a distinction to be drawn 
between the several kinds of cutaneous affections occurring in Eng- 
land and abroad. For instance, the lichen ruber of Hebra is 
rarely seen in England, and not only less frequently, but also not 
in such a marked form as in Vienna. Lupus in Vienna is, on the 
whole, a much more severe disease than in England. Again, the 
prurigo of Hebra does not occur in England, save as the 
greatest rarity. It would seem, too, that it is not the same severe 
disease here in external characters and behaviour. Parasitic 
sycosis is common in France, rare in England and Yienna. 
Psoriasis is infinitely more common in England than elsewhere, 



10 THE MODE OF STUDYING SKIN DISEASES. 

and urticaria in America, and so on. I lay much stress on the fact 
that differences in the same disease are seen here and abroad, and for 
this reason : That I wish it to be understood that the descriptions 
given by foreign writers of skin disease, whilst 'ui the main thev 
apply correctly to English skin diseases, yet vary in many impor- 
tant particulars, and unless the student realizes this fact, and 
many do not, he will be sure to be confused in his reading. Con- 
versely the descriptions given by English authors will not repre- 
sent accurately the characters of diseases as seen abroad. There 
is, indeed a nationality of disease as well as of character or 
physique. 

11th. — A very close relation exists in many instances between 
cutaneous disorders and functional disturbances in internal 
orpins. In some instances hyperaunic changes in the skin and 
mucous membrane have a common origin^*&m lichen planus and 
pityriasis rubra, from disturbance of the sympathetic for example, 
and this is the explanation of the coincidence in the two diseases 
named, of the skin changes, and pyrosis, monorrhagia, and the 
like. In other instances the changes in skin and internal organs, 
instead of having a common origin, react the one upon the other, 
and the important point to notice is this: that the cutaneous 
troubles may be excited and intensified by internal troubles. There 
are four organs whose derangement excites or intensifies skin mis- 
chiefs. The stomach, the liver, the kidney, and the uterus. In 
the vast majority of cases it is rather intensification than excita- 
tion that the practitioner has to deal with. I may add a few 
words as to details under this head. First as to the stomach : of 
course, if the stomach fails in its work the general health will 
suffer, and so the skin will be less able to resist disease or to 
undergo repair ; but there is a more direct influence upon cutaneous 
diseases than this. My own belief is that wherever then 1 is an excess 
of acid secretion, or wnere the secretion of gastric juice is altered 
from a healthy standard, there, probably from the circulation of 
acridities absorbed by the intestinal tract, cutaneous inflammations 
and hyperemias are intensified, as in the case of certain of the 
simpler erythemas of children which are thereby produced. But 
again, stomach irritation, especially in subacute dyspepsia, is 
reflected to the skin, especially that of the face, and excites 
glandular or erythematous changes, as in acne and erythema of the 
face. The face Hushes after meals where digestion is badly per- 
formed, and an exaggeration of this condition is observed in acne 
and erythema, in connexion with marked dyspepsia,. Of course a 
predisposition to acne, with exposure and irritation of the face by 
externals, are elements in the cause of acne, but practically, if 
treatment removes the dyspepsia, the disease often goes. It is not 
difficult to see that if the face of the patient is predisposed to acne, 
dyspepsial troubles reflected to the face may actually excite or 
determine the occurrence of the acne. Pretty much the same may 



THE MODE OF STUDYING SKIN DISEASES. 11 

be said, mutatis mutandis, as regards uterine irritation in women. 
It is a matter of very common observation that uterine troubles 
aggravate erythema of the face, urticaria, and so on. Now 
as regards the liver. It is needless to give proof of the 
truth of the statement that " poisoned blood " — blood I mean 
charged with any effete products — when passing through an 
inflamed skin, say that of eczematous persons, or of an urticaria 
patient, will tend to still further derange the skin of that particular 
subject. And blood is often charged with bile products, and 
tends, as in urticaria and eczema, to intensify the inflammatory 
symptoms, and to retard the cure. This is often seen in children 
who have white stools and who suffer from eczema. In the con- 
nexion between phlegmonous or carbuncular inflammation and the 
diabetic habit, it is possible again to trace the influence of a dis- 
ordered liver — supposing that to be the organ directly concerned 
in the production of sugar — on skin diseases. Lastly, as regards 
the kidney, there are two ways in which this organ may influence 
skin diseases ; the first by the non-removal of watery fluid in 
proper quantities, whereby the occurrence of ©edematous infiltration 
is favoured, as is often seen in eczema of the legs in the old; the 
second by non-excretion of nitrogenous matters, leading to impuri- 
fication of the blood, and the circulation of urea, uric acid, and the 
like, in unusual quantities, through the inflamed or diseased skin, 
giving rise to increased hyperemia. The latter happens in pso- 
riasis, eczema, and other diseases. Of course organic diseases of 
stomach, liver, and kidney involve functional disturbances, and so 
far bring about modifications of skin diseases indirectly, as do purely 
functional disturbances of these organs. From what I have said, 
the reader will have no difficulty in understanding that skin 
diseases require to be regarded not only from a purely surgical 
point of view, as some are wont to assert, but also from that of the 
physician. 

12th. — It is important always to be aware of the fact of the 
bias impressed upon skin diseases by various diatheses — especially 
the syphilitic, the gouty, the strumous, and the nervous. The 
modification of skin diseases by the syphilitic poison (that is, the 
modification which skin diseases tend to and vary frequently un- 
dergo in syphilized subjects,) is a most important fact, and one 
that, as far as I know, is not duly appreciated by any writer or 
teacher on the subject. Even actual syphilitic eruptions are badly 
depicted and described. I venture to say this much: — that when- 
ever the student meets with an untypical eruption — and of course 
I assume that typical cases of disease are at once recognised — un- 
typical either as regards its development, course, main features, or 
duration (save in cases that can be explained by abortive develop- 
ment), and in which there is especially a tendency to pigmentary 
deposit out of ordinary proportion to the tissue change, with a 
disposition to a diminution in the degree of mere surface alteration, 



12 THE MODE OF STUDYING SKIN DISEASES. 

discharge, or scaliness, but an unusual tendency to fibroid deposit, 
— suspicion of syphilis should be excited. (For instance, if an 
eczema instead of discharging becomes thickened and dark!}' pig- 
mented, and this be not explained as the result of chronic con- 
gestion.) Further, if in addition there be an earthy aspect of face, 
semi-rheumatic pains, and a cachectic look, the history of the case 
should be carefully gone into, with a view to detect a syphilitic 
taint. Ulceration unaccounted for in infants or adults by bad 
feeding, the strumous diathesis, or cachexia is susjneious, and 
decidedly so is the presence of rupia-like crusts. I believe that 
the efficacy of so-called alterative doses of bichloride of mercury in 
chronic skin affections is really to be explained by the presence of 
a syphilitic taint in many cases. Xext as to the strumous diathesis. 
Free pus production out of proportion to the degree of inflam- 
matory action, or phlegmonoid inflammation or implication of the 
cellular tissues, are the features that occur as superadditions to 
skin affections in strumous subjects. These are pretty sure indica- 
tions of the need of anti-strumous remedies under all circumstances, 
in conjunction with appropriate remedies for the eczema, the 
lupus, or whatever else may be present. The gouty diathesis is 
present in many persons suffering from eczema, psoriasis, lichen, 
prurigo, and so on. I have already indicated that the circulation 
of urea and uric acid in extra amounts in the blood, is likely to be 
followed by an intensification of hypersemic and inflammatory 
conditions. It is usual to hear medical men talk of "gouty 
eczema," " gouty psoriasis," which are relieved greatly by the use 
of gouty remedies. Such cases were instances of eczema and 
psoriasis, &c, in gouty subjects, the gouty blood acting as an 
irritant to the diseased skin. This is the simple explanation. 
These remarks may suffice to show that certain and different 
constitutional tendencies impress upon skin diseases certain fea- 
tures, which in themselves are to be regarded as important thera- 
peutic guides. 

13th and last. — Observers should accustom themselves to 
examine microscopically the morbid products of skin diseases. 
The surgeon and the physician obtain most valuable indications 
from the examination of the minutest portions of morbid tissue 
and the juice it may yield ; and the dermatologist is much to blame 
for an omission in this respect. The microscope affords very 
valuable assistance in the differential diagnosis of herpes, eczema, 
psoriasis, and tinea especially. For instance, inflammatory pro- 
ducts are absent in psoriasis, present in the other three diseases; 
whilst in all forms of parasitic disease resembling herpes and 
eczema, as in so-called eczema marginatum, fungus elements are 
detected, provided proper care is observed — by this I mean that 
only the thinnest sections or portions of tissue are taken, and the 
tissues are rendered sufficiently transparent by potash. 

Summary. — And now to sum up what I have said as to the rules to 



THE MODE OF STUDYING- SKEN" DISEASES. 13 

be observed in studying skin diseases, I say it is necessary not to 
confound stages with varieties of disease, but to constitute varieties 
on the ground of differences in the general characters of diseases as 
a whole ; to distinguish between accidentals and essentials, so as to 
recognise the proper nature of mere secondary complications and 
occurrences ; to look upon mere surface alterations as indicative of, 
and dependent upon, changes in the deeper parts ; to try and 
ascertain the primary seat of disease as regards nerve, blood, or 
tissue, for therapeutic reasons ; to note if an eruption possesses 
characters which are permanent, transient, or varying from time 
to time, as indicative, when transitory, of some excitation of the 
nerves, and when varying, of an inflammatory disease ; to 
observe if an eruption be uniform or multiform, as suggesting 
in the one case when uniform that the disease is uncomplicated, or 
in the other case when multiform, complication by a second disease, 
or the existence of scabies or syphilis ; to recognise the nationality 
of disease ; not to be misled by the descriptions of foreign der- 
matologists, or to try to use them as absolutely true of the diseases 
of this country ; to make allowance for the bad feeding of the 
lower and the high living of the upper classes in reference to treat- 
ment ; to seek out association of functional and organic diseases 
of internal organs with the diseases of the adult and the aged ; to 
remember, and act upon the relation between functional disorders 
of the stomach, liver, kidneys, and uterus, and certain skin com- 
plaints ; and also the modifying power of diathesis. It is from 
such a liberal and enlarged point of view that I consider skin 
diseases should be studied. 



CHAPTER II. 

THE ANATOMY OF THE SKIN, AND ANATOMICAL CONSIDERATIONS. 

In order to arrive at a correct understanding of the nature of the 
morbid changes that go on in the skin, and to comprehend cor- 
rectly how and where these changes begin, the possession of 
accurate knowledge of the healthy skin in its different parts is 
essential. For pathologists are doing a great deal to define the 
particular structure and seat in which alterations in cutaneous 

Fig. 1. 




(After Neumann.) 



Section of normal skin. a. Horny layer of epidermis, b. Rete Malpighii, or 
mucous layer of epidermis, c. Papillary layer, d. Areolar tissue of cutis, corium. 
e. Panniculus adiposus. /. Spiral excretory duct of sweat gland, g. Straight 
part of excretory duct of sweat gland, h. Convoluted extremity of sweat gland. 
i. Shaft of a fine hair. k. Root of hair. I. Sebaceous gland. 



THE EPIDEEMIS. 15 

diseases commence. Besides, the healthy skin is of course the 
standard of comparison for all changes in the skin, and without 
the clearest perception of what that standard is, the student can 
of course only fall into error from the inability to distinguish 
between what is normal and what is abnormal. 

I need not, as I have only a practical purpose in view, enter 
into any very elaborate detail with regard to the anatomy of the 
skin. I shall content myself with a general resume of the ana- 
tomical structure of the parts to which the dermatologist's attention 
is specially directed as regards the origin of pathological processes. 

In the following description of the structure of 'the skin I have 
followed Biesiadecki, the distinguished Professor of Cracow. His 
elaborate and clear exposition of the matter in an article in 
Strieker's Anatomy is now accessible to every English student, and 
will amply repay careful study on the part of those who desire to 
enter into more elaborate detail than I do here. Through the 
courtesy of Mr. Hutchinson I am enabled to illustrate the text 
with certain of Biesiadecki's own representations of the minute 
anatomy of the different parts of the skin. I have scarcely thought 
it worth while to describe the mode in which sections of the skin 
can be best made and prepared for the microscope. 

The skin is made up of (a) epidermis or cuticle ; (b) cutis, true 
skin, derma, or corium, as it has been severally named ; (c) sub- 
cutaneous cellular tissue, together with appendages — viz., (d) hairs 
and hair follicles, (e) sweat glands, (b) sebaceous glands, and (g) 
nails ; these are all supplied in varying degree with vessels, nerves, 
and lymphatics. The general arrangement of these several parts is 
shown in the accompanying figure 1. 

THE EPIDERMIS. 

The epidermis or uppermost part of the skin is made up of two 
layers, the one the more superficial, called the homy (see a), the 
deeper called the mucous layer or the rete Malpighii (see b). 
Both layers are made up of epithelial cells which differ, however, 
each in certain particulars. 

The homy layer appears, when casually examined under the 
microscope, to be made up of fine lines or fibres, which run parallel 
to the surface, but on manipulating these apparent fibres they are 
seen to consist of flattened-out or nucleated cells which have a 
olygonal shape, their close stratification giving the appearance of 
bres. On tracing the cells downwards they are noted to become 
somewhat larger ; they show an occasional distinct nucleus, whilst 
they are not so much flattened out as are those above. The cells 
of the uppermost or horny stratum vary in size from. 0*1 25'" to 
0-02'". They are not stained by carmine. 

The rete mucosum or Malpighian layer, — the deeper of the two 
layers of the epidermis, lies upon the corium — and projections of this 



i 



16 



THE EPIDERMIS. 



Fig. 2. 



rete dip down between the elevations of the uppermost layer of the 
corium called papillae (see c, fig. 1). The cells of the rete in 
immediate contact with the corium are very small, varying in size 
from -0033'" to *004 /// , they have a nucleus, and are regarded as 
showing a disposition to a columnar form, according to Biesiadecki, 
with their long axes directed perpendicularly to the corium surface 
beneath. Observers have noticed the difficulty of defining their 
cell walls. Biesiadecki" states that "they consist of a slightly 
granular refractile mass of protoplasm, destitute of cell membrane, 
surrounding, though in small quantities only, the compact nucleus." 
Above these lowest cells are larger more clearly defined ones, from 
•002'" to -003'" — cubical in shape and with a nucleus containing two 
nucleoli. Farther upwards, towards — i. e., nearest — the horny layer 
the cells get larger, more distinct, and contain well-defined nuclei. 
They become likewise more and more flattened. Some of the cells 
become stellate or ribbed, and then the minute hair-like processes 
given out by some of them are said to penetrate into adjoining 
cells. From the cells, however, of the upper layer the nuclei may 

fall out, and they then con- 
tain vacuolae. But there are 
certain other and special cell 
elements — spindle - shaped 
corpuscles — described by 
Biesiadecki to be found in 
the rete of living persons, 
and these cells play an im- 
portant part in disease. Bie- 
siadeckif states that " they 
are most easily detected in 
the middle and upper layers 
of the cells forming the mu- 
cous layer, where they can 
be recognised by the refrac- 
tion of their protoplasm and 
by their minute size. They 
are commonly elongated, ap- 
pearing as if they had been 
compressed between two epi- 
thelial cells, or they give off 
fine processes that run be- 
tween the several epithelial 
cells. Their protoplasm is highly refraetible and becomes deeply 
stained by carmine, whilst the nucleus can only be recognised with 
difficulty. This is usually distinguishable, after being subjected to 
the imbibition of carmine. In the deepest cell rows of the mucous 




(After Pagenstecher. ) 

Horizontal section of skin through a pa- 
pilla. The migrating cells are observed as 
dark bands between the epithelial cells and 
amongst the connective tissue of the pa- 
pilla. 



* Strieker's Histology, vol. i. f Loc. cit. 



THE COKIITM. 17 

layer such cells are much more difficult to demonstrate, since they 
offer some points of similarity to the cells of which these are com- 
posed ; for the cells of these layers possess a similar highly refrac- 
tile protoplasm, become deeply stained with carmine, and only 
differ from the former by their well-defined nucleus. The spindle- 
shaped cells are most easily perceived in those cases in which one 
half is found between the cells of the mucous layer, whilst the 
other half is imbedded in the corium. These cells strongly remind 
one of the so-called migratory cells." The migratory cells are 
represented in fig. 2, after Pagenstecher, as multiplied in disease. 
Biesiadecld finds these spindle-shaped cells normally in the sub- 
cutaneous connective tissue, near the blood-vessels and between 
the fibrillse of the corium, and in the mucous layer or rete. They 
increase largely in number in certain diseases, and it is thought 
that in health those in the rete have migrated from the corium. 
The pigment is contained in the cells of the rete. 

Now in regarding the two (horny and mucous) layers of the 
cuticle or epidermis as a whole, there are certain points of im- 
portance to be aware of. In the first place, the horny layer varies 
much in thickness at different places from 1-65 to 1 line, but the 
mucous layer is fairly uniform in this respect, being generally 
from 1-65 to l-20th of a line. The epidermis is thin about the face, 
and thickest on the sole of the foot and often the palm of the hand. 
It is believed that non-medullated nerve fibres run up into the 
rete or Malpighian layer, and there form a network.* 

THE CORIUM. 

The corium (see d, fig. 1) is an important part of the skin, and 
is made up of connective-tissue fibres and corpuscles, intermingled 
with elastic fibres, forming a closer plexus above and a looser one 
below, the whole being woven into a densish mass with smallish 
meshes. It has two parts — an upper or papillary layer, and a deeper 
part. The papillary part is composed of projections upwards, in 
the form of fringe-like processes, called papillae (see c, fig. 1), which 
are projected into the rete above ; the rete dipping down into the 
inter-papillary parts. The deeper part differs in the fact that the 
texture is somewhat more open than in the papillary part. There 
is no distinct line of demarcation between the two. 

^ The papillse in the papillary part vary in size and aspect in 
different parts of the skin. They are pointed or thread-like about 
the fingers, and club-shaped or rounded over the general surface 
of the body. On the palm of the hand, about the nipple, and the 
sole of the foot, they are longest and largest, being often 66 
to 1 m. They are shortest on the face. They are of two kinds — 



* See Langerhaus, Virch. Archiv, Band xliv. 2 and 3 Heft. Podcopaew, Arch, 
fur Mikroscop. Anat. ; Band v. Heft 4. 
2 



18 



THE COKEUM. 



nervous, containing nerve fibres ending in tactile corpuscles, and 
vascular, containing blood-vessels in the form of a loop. (see fig. 3, 
from Biesiadecki). 

Some believe that the corium and rete are separated by a distinct 
membrane ; but this is admitted by most to be true only as regards 
the foetus, and not the adult. Biesiadecki and others affirm its 
presence, and that it is ribbed and projects fine fibres into the 
mucous layer. 

There are, in addition, spindle-shaped cells, or cells anastomozing 
by processes, amongst the connective-tissue bundles in the substance 
of the corium and around the vessels. 

It is said moreover that cells, supposed to be escaped blood-cells, 
are to be seen normally, outside the vessels in the corium. 



Fig. 3. 




(After Biesiadecki.) 

Prepared in chromic acid. a. Vascular, b. Nervous papilla, c. Blood- 
vessel, d Medullated nerve fibre enclosed in a thick nucleated sheath. 
e. Tactile corpuscle. /. Transversely divided nerve fibres. 

The thickness of the corium varies. It is thinnest about the eye- 
lids and prepuce, being about '56 m. ; on the face, scrotum, and body 
generally, it is thicker. On the sole of the foot and palm of hand 
it is thickest, being from 2*25 — 2-28 of a millimetre (Krause). 

The corium is well supplied with vessels, lymphatics, and nerves. 
The vessels come np from the connective tissue below, give off 
branches to the fat and the glands, then constitute a network 
which sends off more or less obliquely twigs to form a longitudinal 
plexus along the base of the papillae, from whence finally capillary 



HAIE FOLLICLE. 19 

loops are supplied to most of the papillae (see fig. 3, c). The 
lymphatics have much the same arrangement as the blood-vessels. 
The plexuses however are situated beneath those formed by the 
capillaries, but no lymphatics are supplied to the papillae. The 
spaces normally seen between the connective-tissue fibres are 
supposed to be lymphatic spaces ; they have no proper boundaries. 
The blood-vessels and lymphatics are thought to communicate, 
though this has not been proved, by means of perivascular spaces 
where the blood-vessels and lymphatics run together, the walls of 
these spaces being formed by the connective tissue around. 

Nerves accompany the blood-vessels coming up from below, and 
are of two kinds, medullated and non-medullated ; the former go 
with the tactile and Pacinian corpuscles (see fig. 3, d and,/), and the 
latter form, it is believed (Podcopaew*), a fine network below the 
rete, in connexion with the capillary plexus, and are in communi- 
cation with those found in the rete. Non-medullated fibres also 
run with the capillaries, which supply the vascular papillae. 

The sebaceous glands are situated in the corium (see fig. 4, t). 

THE SUBCUTANEOUS CELLULAR TISSUE. 

-This is nothing but a lax network of connective tissue. The 
bundles of fibres, " usually cylindrical, exhibit constrictions at vari- 
ous points like those of the arachnoid membrane, and consist of a 
number of sinuous fibre's of connective tissue, between which lie 
numerous fusiform and connective-tissue corpuscles of various 
forms and dimensions " (Biesiadecki). It is this part in which the 
fat cells are collected in the meshes of the fibres, the only seats 
destitute of fat being the eyelids, penis, scrotum, and ears. 
The fat I need not describe. The fusiform cells that lie between 
the bundles and fibres of the connective tissue are connected with 
these fibres by means of processes given off one at either end, 
with other minor ones elsewhere. Other fusiform cells, without 
processes (the migrating cells), and small cells like blood-cells, are 
observed, the latter being contiguous to the vessels. Biesiadecki 
and others affirm that there are transitional phases of cells, between 
the round, and the fusiform ones with processes. There is no line 
of demarcation between the corium above and the subcutanuous 
tissue below. 

THE HAIR FOLLICLE AND SEBACEOUS GLANDS. 
(A.) HAIE FOLLICLE. 

I take these structures together on account of the' ' close anato- 
mical relationship, for the sebaceous glands open i. .o the upper 
part of the hair follicles. 

The hair follicle consists of a deeply-seated part and an excretory 

*Loc. cit. 



20 



HAIE FOLLICLE. 



Fig. 4 




(After Biesiadecki.) 



duct, which is somewhat dilated. At 
the bottom of the deeply-seated part 
is a projection called the papilla, at 
which the hair cells are formed (see 
fig. 4). The hair follicles reach 
well down in the case of the larger 
ones into the subcutaneous cellular 
tissue (fig. 4). 

The hair follicle may be regarded 
as a depression of the skin ; the 
papilla at its blind end represent- 
ing one of the ordinary papillae of 
the skin. 

The wall or sac of the hair is 
formed of connective tissue, repre- 
senting the corium ; and is supplied 
with vessels and nerves. I need not 
describe it. It has attached to it a 
bundle of muscular fibres — the 
anector pili (fig. 4, n). The papilla (p) 
is made up of connective tissue, but 
in whicli the cells predominate, and 
is supplied by small arteries that 
divide and join once and again ; 
nerve fibres* have been traced up to 
its neck. Between the hair and the 
true follicular wall are certain struc- 
tures that ensheath the hair, and are 
called the outer and inner root sheath 
of the hair (see fig. 4, f & g). The 
oicter root sheath is regarded as the 
inverted layer of the rete mucosum. 
It does not reach to the lower part 
of the bulb, but ends about the level 
of the apex of the papilla. It is 
made up of closely packed cells like 
those of the rete, the innermost 
(those nearest the hair) being flat- 
tened out more than those more ex- 
ternally placed, which are inclined 
to be columnar. The cells are seve- 
ral lines deep, except above and 



Hair from beard. a. Excretory duct. b. Neck of hair follicle, d. Ezternal 
sheath of hair follicle, e. Internal sheath of hair follicle, f External root sheath of 
hair. g. Internal root sheath of hair. h. Cortical substance . a;. Medulla of hair. I. 
Eoot of hair. m. Fat cells, n. Anector pili. o. Papillse of skin. p. Papillse of 
hair. s. Rete mucosum. t. Sebaceous gland, ep. Epidermis, which is continued 
into the follicle. 



SEBACEOUS GLANDS. 21 

below where the sheath ends. The inner root sheath (see fig. 4, g) 
is held to be made up of two layers, the outer next the outer 
root sheath, is called the layer of Henle, and the inner layer next 
the hair — Huxley's layer. The former, or Henle's layer, has 
the character of fenestrated membrane — a membrane made up of 
long fusiform cells with spaces between them. Huxley's layer 
is produced as a special layer at the root of the hair. It consists at 
first of fusiform cells with nuclei, but the latter disappear above, 
where the layer is homogeneous. It is the union of these two layers 
(those of Henle and Huxley) that forms the inner root sheath ; and 
it extends upwards to the neck of the follicle. But I fail to see 
that it does not continue upwards and blend with the epidermic 
structures, indeed the inner root sheath represents the horny layer 
of the epidermis, as does the outer root sheath the rete. 

I do not think it necessary to give a detailed description of the 
hair. 

SEBACEOUS GLANDS. 

These appendages are in close connexion with the hair follicle, as 
before stated, and they are seated in the corium: their ducts 
open into the hair follicle at the neck in the case of the larger hair 
follicles ; but in the case of the smaller, or downy hairs, the relative 
position of the glands and hair follicle is altered, so that the minute 
hair follicle leads into the duct of the sebaceous gland, which opens 
directly on the surface. These glands are absent from the palm of 
the hand, the sole of the foot, and the dorsum of the third phalanges 
of the fingers and toes, and there are few about the penis. The 
largest are found about the nose, scrotum, anus, and labia. 

the glands are composed of excretory ducts, continuous above 
with the hair follicle and of true gland structure (see fig. 4). The 
gland structure may take the form of a single sac, or be made up 
of from two to twenty lobules or acini that open into the excretory 
duct. The gland wall itself is made up of " a transparent and 
colourless nucleated membrane that is apparently destitute of 
structure, but when treated with nitrate of silver exhibits groups of 
cells ; externally it is bounded by a dense layer of connective tissue 
with elastic fibres, which is traversed by a moderately close vas- 
cular plexus. The sebaceous follicles are not known to possess 
any special supply of either lymphatics or nerves " (Biesiadecki). 
The glands are filled with cells which may be regarded as the 
representatives of the rete Malpighii — at least, all the cells are 
like epithelial cells, but the cells at the outer part of the glands 
are exactly like those of the rete, save that they possess more 
decided nuclei. All the cells tend to undergo fatty change. The 
glands are formed in the foetus originally as offshoots from the 
outer root sheath of the hair follicle. 



22 



MUSCLES OF THE SKIN. 



THE SWEAT GLANDS. 

These glands (see fig. 1, f and h) lie more deeply than the se- 
baceous, for they reach to the lower part of the corium or the 
subcutaneous tissue, and lie among the fat cells, forming coils 
(see fig. 5). The excretory duct runs up through the corium, enters 
the rete between the papillae, then passes up in a spiral direction 
through the epidermis to the surface. The openings are large, 
funnel-shaped, very plainly seen, and in regular disposition in the 
hands and feet, but in other places the openings are in groups 
of two or three, and irregularly placed. The wall of the duct is 
formed below by the corium, and the duct is lined by epithelial 
cells, but in the rete mucosum and above there is no true wall, the 
boundary being formed by the epidermic cells. The gland itself 
has a diameter of from *15 to # 5 of a millimetre. In the axilla 
it may be as large as from 1 to 5 millimetres. It is made up of 
the membranous duct very freely coiled, the coils being held 
together by connective tissue, and the ending of the coil being in the 
centre of the gland. Vessels form a network about the gland and 
in the connective tissue that surrounds it, which latter contains 
spindle-shaped cells. The contents of the gland may be regarded 
as a single layer of polygonal cells. 

MUSCLES OF THE SKIN. 



There appear to be two kinds of muscles found in the skin — the 
voluntary, or striated, and the involuntary. The former are to be 

detected in the face, beard, and 



Fig. 5 



I 



rM 



; 



(After Biesiadecki. ) 

Coils of gland divided transversely 
a. Sheath of gland, b. Enchyma cells, 
c. G-land tube. d. Divided blood-vessel, 
e, f. Connective tissue forming capsule. 



the hair follicle, 



nose, according to Biesiadecki, 
"ascending sometimes obliquely, 
sometimes vertically, between 
the hairs and the sebaceous fol- 
licles to terminate in the co- 
rium." They come from below. 
The organic or non-striated 
muscles are more abundant. 
They occur forming a kind of 
network in the scrotum. Over 
the general surface of the skin 
bands of fibres are detected in 
connexion with the hair follicle, 
and are called arrectores jyili (see 
fig. 4). These muscles exist as 
single fasciculi *045 to *22 of 
a millimetre 
sometimes 
in immediate relation to the sebaceous glands 



, sometimes on one, 
on both sides of 



which they enclose more or less. They run from the corium above 



NAILS. 



23 



to the part of the hair follicle just below the glands, and there end 
in the inner sheath of the hair follicle. Some authors affirm that 
bundles go down to the subcutaneous tissue and send _ off vertical 
and horizontal branches. Neumann, who is of this opinion, states 
that bands run above and under the sweat glands, more especially 
in the axilla. He describes also independent bundles of muscle in 
the corium quite unconnected with the hair follicles. 

NAILS. 
The nails, and the part upon which they lie, are essentially the 
same in structure as the skin in its different parts, only that 
the horny layer is more developed, forming the actual nail. 
Posteriorly, the nail is fitted into a groove ; the part fitting into 
the recess is called the root, and the portion underlying the nail 




*$, 






mm 



^2i^LiL z:_ . _/>l, ^1 



>£ 



(After Biesiadecki. ) 

a. Nail. b. Loose horny layer beneath it. c. Mucous layer, d. Trans- 
versely divided nail ridges (papillae) with injected vessels, e. Nail fold 
deprived of papillae. /. Horny layer of nail fold which has been deposited 
on the nail. g. Papilla of skin of back of hand. 

is that which represents the corium — it is, in fact, the corium ; it 
bears, however, the name of matrix. Between the nail itself and 
the matrix is the rete mucosum ; in fact ' the bed of the nail may 
be described as consisting of corium with the sub-connective tissue 
beneath, and the rete above. 

As in the case of the skin the rete dips down between the papil- 
lary projections of the corium of the nail. 

The corium itself, or matrix, is divided into two parts, which 
are separated by a more or less convex line seen through the nail 
and knpwn as the lunula. The hindermost of these two divisions 
has its papillae directed forward, less distinct, and more closely 
seated together. The front portion is thrown into longitudinal 
folds, and upon these are seated the papillae. These folds are 
produced by the peculiar disposition of bundles of connective 
tissue in the structures beneath. The matrix towards the front 



24 HISTOLOGICAL CHANGES. 

part of the nail is covered by cells that are more and more horny, 
whereas over the posterior surface of the matrix (the root of the 
nail), these cells are softer. In fact, the part of the nail matrix 
behind the lunula is the spot where the nail is formed. The soft 
cells are directed forward, guided by the fold of the skin over 
the nail at its root — which fold lacks glands, and papillae on the 
surface applied to the nail — becoming more horny as they advance. 
The posterior portion of the matrix is compared by Biesiadecki to 
the papilla of the hair, and the fold of skin over the root to the hair 
follicule. The structure of the nail is well represented in fig. 6. 

GENERAL REMARKS IN RELATION TO HISTOLOGICAL CHANGES. 

A correct knowledge of the anatomy of the skin is an immense 
aid to the right comprehension of morbid changes going on in the 
skin. Of course, in discussing the general pathology of the skin 
and the morbid anatomy of particular diseases I shall indicate the 
seat, mode of origin, and character of diseased processes ; but 
there are certain general considerations relating to these processes 
that may very fitly be referred to in this place. 

The epithelial stratum of the skin, made up of the horny and 
mucous (rete Malpighii) layers, are the special seat of a number of 
morbid processes. In parenchymatous inflammation as in small- 
pox, the first stage seems to be a great increase in the cells of the 
rete, and the pustule subsequently produced is formed bodily in 
the rete, its walls being formed by altered rete cells, stretched into 
fibres and enclosing pus cells. In the formation of vesicles and 
bullae, the rete is chiefly concerned. In some cases of non-inflam- 
matory diseases, the epidermic cells are found to have undergone 
special changes, or to have been arrested in their development, as 
in psoriasis. 

The relation of the epidermis to the papillary layer, in regard 
to diseased action, is a matter of no little importance. In a most 
excellent contribution to the subject, Dr. Auspitz* argues that it 
is not a correct view, as generally held, that the papillary layer 
grows actively as it were with the epidermic layer, the latter re- 
maining passive, and receiving the impressions of the growing 
papillae from below. Tie thinks that the reverse is really true, 
that the papillae are the result of the growth inwards of the rete 
mucosum into the corium, in the form of columnar masses of its 
component cells. In order to illustrate what he means I may 
refer to his conclusions in regard to the production of diseases 
from the growth inwards of and resultant changes in the papillary 
layer. They are : — 

1. In hyperaeinic and inflammatory processes occurring in the skin, the 

* Ueber das Verhaltniss der Oberhaut zur Papillarschicht insbesondere bei 
pathologischen Zustander der Haut. Von Dr. Auspitz, Archiv fur Derm, and Syph. 
1870-1. 



HISTOLOGICAL CHANGES. 25 

papillse are found to be only succulent and slightly swollen ; but no modifications 
of form occur, unless consecutive to secondary change in the Malpighian stratum. 
2. In simple and lymphatic hypertrophy of the connective-tissue matrix, as well 
as in cell-infiltrations of the corium, the same law holds. 3. In the keratoses, or 
horn-producing affections — ichthyosis —there is either no change in the form or 
size of the papillse, or it is due only to the pressure of the hypertrophied horny 
layer. The prismatic and columnar forms of the latter are by no means dependent 
on the papillse of the cutis. 4. The papillomata (warts, condylomata, epithelioma) 
originate essentially in an active neoplastic process taking place in the rete, which 
penetrates to a greater or less extent into the likewise hypertrophied connective- 
tissue matrix of the corium. The papillse of the cutis here, too, perform only a 
passive role, their elongation and dendritic form being occasioned by the hyper- 
trophy of the epidermis ; whilst the elevation of the surface of the skin is due to 
hypertrophy of both. 5. An outgrowth of the connective tissue of the skin some- 
times occurs, but is never dependent on the pre -existent papillse. 6. There is no 
essential anatomical difference between the several forms of papillomata, warts, 
pointed condylomata, and cauliforrn excrescences. The syphilitic condyloma differs 
from these only through the specific cell-infiltration of the corium. 7. Epithe- 
lioma represents exquisitely the types of the hypertrophic growth inwards of the 
epidermis into the connective-tissue matrix. — (See fig. 52.) 

I will only remark here that a modified explanation may be 
given of the penetration inwards of the rete cells. It may be 
argued that if the rete and the papillary layer simultaneously 
augment, or even the latter increases by itself, the rete masses 
must be left more deeply placed from the surface ; and if they con- 
tinue to grow, as in epithelial cancers for example, it may seem as 
though the extension inwards was due solely to an actual growth 
inwards of the rete, and an elevation of the papilla secondarily. 
But the question is one for accurate observation, and anything 
that Dr. Auspitz states deserves the most attentive consideration. 
The rete is an important pathological ground moreover, from 
the fact that in most inflammatory processes there is to be found 
in it a great increase of the spindle-shaped or migrating corpuscles. 
Lastly, it is now established that cutaneous cancers originate 
in a morbid change in the cells of the Malpighian layer, and by 
the disordered growth of these same cells in masses from their 
inter-papillary parts, into the corium. This is an undoubted fact, 
and gives countenance to Dr. Auspitz's view above referred to. 

The corium is also the seat of very important pathological 
changes that originate in its substance and various alterations of 
its component elements. It is the essential seat, of course, of 
hypersemic changes : and according as the longitudinal plexus, or 
the^ papillary vascular loops, or both are implicated, the redness 
varies in aspect. The corium is, further, especially its papillary 
layer, the early seat of many inflammatory changes, the vessels 
dilating, and permitting moreover the escape of white blood cells 
into tks corial textures, and likewise serum, which makes its way 
to the rete, forming vesicles, &c. Then again, the fibrous elements 
of the corium furnish the migrating or fusiform cells that appear 
in great numbers in chronic inflammations especially, and migrate 
to the rete. The corium is the chief seat, moreover, of neoplasmata 
other than cancerous, as in the case of syphilis and leprosy; 



26 HISTOLOGICAL CHANGES. 

these new growths, supposedly originating from the connective- 
tissue elements. A simple increase of the latter, too, is held to 
constitute certain other diseases, such as pachydermia, keloid, &c. 
The vacuolse and lymphatic spaces are also seats of particular 
changes, as in leprosy. A knowledge of. the structure and 
peculiarities of hair follicles and sebaceous glands is not less impor- 
tant in relation to the origin of many common diseases, as acne, 
fibroma, cancer, lichen planus. Without it the student will 
attain little real knowledge of the pathology and therapeutics of 
these frequently-occurring affections. 

In the case of the nail, unless a student knew what was the 
part of the matrix at which the nail was actually formed, he 
would be at a loss to diagnose a syphilitic from a non-syphilitic 
growth, or to comprehend the difference which arises when inflam- 
mation attacks now the posterior part of the matrix (where the 
nail is formed), or now the anterior portion ; nor would be able 
to explain the predilection of parasites for the root of the nail. 

I hope that even these few comments will show how necessary it 
is for the dermatologist to possess an accurate and detailed know- 
ledge of the structure of the skin in all its parts. 



CHAPTEE III. 

GENERAL PATHOLOGY OF THE SKIN.— ELEMENTARY LESIONS. 

The next subject is the nature and varieties of what are termed 
" elementary lesions," or the types of form and aspect resulting from 
morbid changes in the skin. The elementary lesions, or external 
forms, if the term be better liked, consist of maculae or stains ; 
erythema or redness; wheals; papules, or " pimples ;" squamse or 
scales ; vesicles, or little bladders ; blebs, or large vesicles ; pustules, 
or mattery heads ; and tubercula, or lumps — eight in all. These 
are followed by certain secondary changes, viz. : — excoriations, 
crusts, stainings, ulcerations, scars, fissures, and so on. 

There is one remark I would make with a view of helping the 
reader to avoid a common error in regard to these lesions. It is 
this, that the different typical forms of lesions embrace or include 
each of them several varieties, and the designation of each typical 
form or lesion is to be regarded as a generic term, applicable to 
several varieties of the same lesion. It is not enough, for instance, 
to say a papule is present. Since there are various kinds of papules, 
it is necessary to state what particular kind of pustule is meant. 
When it is said a tubercle is present, the class to which the lesion 
belongs has only been denned ; the tubercle may be that of a cancer, 
lupus, or syphilis. I am quite convinced that one of the commonest 
errors into wich those who are studying skin diseases fall is the 
neglect to recognise the fact that there are several different 
varieties of the same kind of elementary lesions, and their confusion 
of these several different varieties. This is emphatically the case 
with papules. With this caution I proceed to point out the several 
varieties of elementary lesions. 

MACULE. 

Maculce, or Stains (discolorations of the skin) are of various 
kinds ; excluding ksemurrhagic stains, as in purpura, there are three 
different kinds of maculse — {pigmentary, parasitic, and chemical.) 
So that whenever a discoloration of the skin, which is not explained 
by the escape of blood from vessels is met with, the observer has 
to decide to which of these classes it belongs, and the decision is 
an easy one. The staining by iodine, nitrate of silver, either taken 
internally for a long time or applied externally, and the yellow 
discolorations induced by bile staining are at once diagnosed ; and 



20 ERYTHEMA. 

there is no difficulty as regards the discoloration of the parasitic 
disease — tinea, or pityriasis versicolor, which is chiefly due to the 
presence of the fungus elements. In this disease, scales can be % 
scraped away with the finger from the discoloured patch, which is 
moreover slightly raised and itchy, none of which features belong to 
pigmentary stainings. The pigmentary discolorations are the most 
numerous, and will be dealt with in detail in Chapter XIX. 

ERYTHEMA. 

Erythema, or simply redness, or if it be preferred, hypercemia, is 
engorgement of the capillary plexuses of the skin. This condition 
may constitute — though caused by different exciting agencies — the 
chief and perhaps sole disease present, or it may form merely a part, 
and that a mere secondary one, in many diseases. Dermatologists 
make the usual division of congestion into active and passive. 
Passive congestion is the result usually of mechanical impediment 
to the venous circulation, and it is of a dull colour and bluish, the 
surface being cold. Active congestion, well marked, is characterized 
by half a dozen signs : — {a) redness, which may be uniform, or 
punctate or blotchy, according to the extent of the capillary plexus 
involved ; (b) swelling, the result of the increased amount of blood 
in the part, and effusion from the vessels; (c) a rise in tem- 
perature ; (d) disordered sensation, ex. gr. : tingling, itching, pain ; 
(e) an acute course as the rule, and (f) its being followed by 
secondary changes — ex., desquamation, exudation, and hypertrophy. 
Now of course hyperemia or erythema is an item in most skin 
diseases, in all inflammatory diseases especially, but in a few it is 
the primary and the sole condition, and does not play only a 
very secondary part in the real disease. It is to such a condition 
that the term erythema is applied in its more limited sense, and it 
is produced firstly by a number of local causes — all irritants in fact ; 
and secondly in connexion with slight derangements of the con- 
stitutional condition, involving assimilative errors or febrile dis- 
turbance. The erythema and its direct consequences are all that 
is present, and these occurrences seem to be connected, as I have 
said, with some mild febrile general disturbance, as in erythema 
multiforme, roseola, and rosalia. These differ from the exanthemata 
in not running so definite a course, in not being contagious or 
dependent upon the action of specific poisons, as far as can be 
determined. All this is very simple. In looking at hyperemia 
from a wider point of view, it has been usual to say that ery- 
themata (hypersemise) may be grouped into three classes : — 
(1) Those forms which constitute the sole disease, as in local 
hyperemia, produced by local causes — ex., irritants of all kinds, 
and heat. (2) Those which form, the main feature in general 
disorders, and are so important as really to constitute the disease 
that requires treatment — ex., the ordinary febrile erythemata; 



WHEALS. 29 

and here the rash is more or less partial. (3) Those which con- 
stitute a prominent feature in more serious and fatal affections — 
ex., measles, scarlatina, the acute specific diseases, and in which 
the rash is general over the skin. In some of these cases true 
inflammation — viz., hyperemia, followed by the formation of new 
products, succeeds. 

WHEALS. 

Under this head I may refer to the nature of wheals or pomphi. 
These are elevated hyperaemie swellings, which in' their fully de- 
veloped condition have a pale whitish centre, and are typically 
portrayed in the sting of the nettle. Their chief characteristic 
is the suddenness with which they are developed, and the equal 
rapidity with which they disappear. There is sudden dilatation of 
a bunch of vessels, accompanied by heat and itching, then a 
certain amount of effusion of serosity ; the vessels recover their 
tonicity, the fluid is absorbed, and all appearance of change vanishes. 
I expect that although the vessels in the actual hypersemic spot are 
dilated, yet at the circumference the arteries are contracted, and it 
is the relaxation of this contraction which soon occurs that explains 
the rapid subsidence of the hypersemia. It has been held that wheals 
are due to contraction of the muscular fibres of the skin, and on the 
ground that if two scratches be made, these are at once succeeded 
by red lines, immediately developed in urticaria, in the seat of the 
scratches, -which lines approximate ; but it is easy to see another, ex- 
planation of the approximation . The effect of the alteration in the 
relation of the parts brought about by the effusion of fluid, as in the 
elevation of the central part of a wheal, must be to approximate the 
parts on either side in the transverse diameter. This may be seen 
by pinching up into a cone the side of an india-rubber ball. 

The white aspect of the centre of the wheal is produced by the 
pressing out of the blood, away from the part of the skin, where the 
pressure of the effused fluid is greatest — that is, in the central part. 
If the finger be placed upon a large red spot, and pressure be 
made in its centre, the blood is squeezed of course therefrom, and 
the part gets pale for the moment. Now it is only necessary 
to suppose that pressure is made from within outwards, to 
form a correct idea of what happens in the formation of a 
wheal. The rapidly effused fluid causes the central reddened part 
to become more and more tense, till at last the blood in the central 
part is pressed away and the part looks pale. The swelling of the 
wheal $s a whole is of course greatest at the time the centre 
whitens, and it is at this time that it feels most tense. As the 
effusion begins to disappear, the tension in the centre of the wheal 
lessens, and the blood gradually returns to fill the capillaries, whilst 
the red colour reappears. This physical explanation at once 
accounts for the whitish appearance seen in the central part of a 
wheal. Generally speaking, the effusion rapidly subsides, but it 



30 PAPULA. 

may be so persistent or so extreme that little bullae are formed. 
This is not at all common however in nettle-rash (urticaria). 

In children the hyperemia is followed by the deposit of a certain 
amount of lymph, and wheals in children mostly leave behind 
minute fleshy (lymph) papules. This sequence is characteristic 
with lichen urticatus. 

PAPULAE. 

Papules. — They are simply pimples. 

It is emphatically in regard to papules that it is necessary 
to remember that each type of elementary lesion includes or has 
reference to several varieties. It is wonderful with what perti- 
nacity students decline to go a step farther than the diagnosis of 
a papule in the rough, if I may so say. Having found a papule 
■ — a pimple — that contents them. They somehow have a horror 
of recognising the fact that there are many kinds of papules ; 
and having determined that a papule is present, it is necessary 
to go farther and define its exact origin and character. Now 
there are just half a dozen kinds of papulae or pimples, (1) those 
produced by hyperaemia of the papillae of the skin, forming little 
bright red, minute points, as in the erythemata; (2) those 
formed by turgescence and consequent erection of the follicles of 
the skin, the perspiratory or pilous — there is hyperaemia alone here, 
as one sees about patches of eczema ; (3) papules formed by the 
deposition of lymph or the like in the walls and about the follicles, 
as for instance in lichen planus, lichen pilaris ; (4) papules formed 
by solid lymph formations in the actual derma, especially its 
papillary layer, as in prurigo — I do not mean phthiriasis : — or 
by new cell-growths as in syphilis ; (5) papules formed by 
collections of epithelial or sebaceous matter within the follicles 
and the projection of these collections, as in pityriasis pilaris 
and lichen scrophulosorum ; (6) papules formed by hypertrophy 
of normal structures — ex., the papillae of the derma, forming 
small warts or minute fibrous outgrowths. The term papule 
should be really applied to the pale flesh-coloured pimples, formed 
by solid lymph, or in prurigo, and the dark ones of lichen planus. 
But I may profitably add a few words in detail under the several 
heads. 

ITyperaemic papillae, soft, red and small, speak for themselves. 

Turgescent and erected follicles are frequently present, as small 
red papulae, in many different skin diseases, where there is much 
irritation or scratching. So they occur in scabies, in phthiriasis, 
around patches of irritable eczema, and running on to the pustular 
stage, in croton-oil eruption, and so on. The hair follicles are the 
seat of papules under these circumstances, but the perspiratory 
follicles are those which are involved in lichen tropicus or prickly 
heat and in strophulus, as I believe. I am in the habit of drawing 
a distinction between these same kind of papules — viz., those formed 



PAPULA. 31 

by tiirgescent follicles and the early condition of vesicles (and 
pustules). The confusion of the two is often made in eczema, for 
instance. It will be seen presently that in eczema one of the 
first things that occurs is serous effusion into the papillary layer 
of the skin, and before sufficient time has elapsed for a vesicle 
to be formed by the effusion of abundant serosity, a papule is 
present. So in variola, before pus-cells are formed in the rete, so 
as to come to the surface, a papular elevation is produced. But — 
and this is the point — these papulae, which are the transitional stages 
of other lesions, cannot — should not, rather — be confounded with 
papules formed by erected and congested follicles. For example, 
in eczema the two kinds of papules will oftentimes be found 
together, and each kind implies different things — one, the 
papule which is running on to become the vesicle, indicates the 
real and active disease ; and the other, the congested and erected 
follicle papule, that there is a good deal of disturbance of the 
parts around the real eczema ; and it indicates the need of soothing 
treatment. These remarks may teach another lesson of some 
moment — that it is not only important to discern the differences in 
the naked-eye characters of papulae, but also their intimate 
pathologies. I said in regard of diseases in general, that it 
is wrong to divorce stages one from the other, and make them 
separate entities. So in regard to elementary lesions. The 
vesico-pustule of eczema or the pustule of variola has each its 
papular stage, which has peculiarities of its own, and which 
should be described and taken in connection with the eruptive 
manifestation as a whole. To those papules that become pustules 
or vesicles I would use the term the papular stage of this or 
that, and restrict the term papule in the abstract to pimples that 
begin as and remain papules during their entire course. 

The third kind of papule is that formed by deposit of lymph or 
cell growth about the follicular wall, as in syphilitic lichen, for 
instance, where the follicles generally of the body are involved. 
This state may be the consequence of hyperaemia. It may be very 
limited, in which case lichen pilaris results, or it may lead to 
a special alteration of the deep structures of the follicles. In the 
former case it is the superficial part which is affected, and the 
papules are small ; in the latter, it is the deeper part, and the 
papules are larger as in lichen planus. 

But I pass on to notice the fourth kind of papule — that formed, 
by effusion of lymph into or new growth in the derma. This is 
seen in lichen simplex — a very uncommon disease, in prurigo and 
neoplasmata. In this there is, as proved by microscopic examina- 
tion, effusion of lymph into the papillae, or new production of tissue, 
forming new solid formations, the size of from pin-heads to split 
peas. Lymph papules itch and are scratched ; at first they are pale, 
firm, hard, knotty-feeling little lumps, but from being scratched 
exhibit excoriated apices, which are discoloured by dried blood — 



32 VESICLES AND BULL^. 

the typical condition of a so-called prnriginous papule. Any papule 
that itches and has a central speck of dried blood is said to be 
" prnriginous." But all kinds of pimples, as congested follicles, 
new formations, and so on,* usually itch ; they are then scratched and 
hence may become " prnriginous," as in scabies, eczema, phthiriasis. 
When therefore it is said a papule is prnriginous it is necessary still 
to define the nature of the papule before making a correct diagnosis. 

I should say that large and flat papular elevations occur in 
pruritus followed by scratching. They are produced by enlarge- 
ment (oedema) of the little areas of the skin enclosed by the natural 
furrows. 

In syphilis amall solid papules of a pale or fleshy colour are 
formed. These may be " follicular," and then form as a conse- 
quence of hyperemia of the follicles. They are mostly formed by 
little masses of granulation tissue in the true skin. They frequently 
pustulate or enlarge into tubercles. This tendency to interchange 
of character between several varieties of elementary lesions, is a 
characteristic of syphilitic eruptions. 

The fifth kind of papule, that formed by collections of epithelial 
matter within the follicles, explains itself ; the little plugs can be 
removed and are seen to be made up of epithelial matter. Mis- 
takes in diagnosis are likely to occur when hypersemia of the follicle 
is present, and the papules look reddish. I need say nothing of the 
sixth kind of papule. 

VESICLES AND BULLiE. 

Vesicles and Bullae. — It is usual to describe a vesicle as a minute, 
and a bulla, as a larger, bladder produced by the upraising of the 
cuticle by fluid, but it is necessary that I should be much more 
definite than this. 

Yesicles vary somewhat as to their structure, their anatomical 
seat, and the source and character of their contents. The simplest 
kind of vesicle is that which occurs in sudamina and miliaria (see 
fig. 91). It is formed by a collection of sweat between the horny 
layers of the epidermis, and in a single compartment, as shown 
by my friend Dr. Haight,* of New York, who has recently inves- 
tigated the subject of the structure of vesicles with great success. 
The roof and floor of the vesicles in sudamina are formed by 
layers of the horny epidermic cells, not colouring in carmine, and 
into the vesicle, which is not chambered, opens a sweat duct, the 
epithelium of which is clouded and swollen, and no doubt blocks 
up the winding duct near the outlet. In pemphigus there is a 
collection of fluid, not between the horny layer of the epidermis, 
but between the horny and the mucous, or Malpighian or rete layer ; 
the cells of the lower strata being drawn out, and having fine 
cavities between them, produced by the effused fluid, but not so 
as to destroy the single character of the main chamber containing 

* Sitzungsberichte der Akademie in Wien, 1868, Band lvii. 



VESICLES AND BULLAE. 33 

the fluid, the papillae of the corium being likewise swollen with 
serum. 

In the formation of a blister, as for example in the case of a burn, 
Biesiadecki's observations go to show, that the vessels of the papillae 
dilate in the first place, and give out much serous fluid ; this fluid 
permeates the tissues and reaches the rete mucosum or Malpighian 
layer. The cells of the rete do not seem to be able to imbibe the 
fluid, and are pushed forward by the fluid. Adhering in part below, 
and being thus put upon the stretch, they elongate, and are Anally 
converted into fibres, in which no trace of nucleus can be seen. 
The epidermis is thus raised from the papillae, but there are fine 
fibres (the stretched cells of the rete) running from below up- 
wards in the cavity of the blister (see fig. 7). These fibres are 
torn across and hang loose in the cavity, in proportion as the effu- 
sion is great. But there is one part where the epidermis is not 
disturbed or detached, and that is, as may be well imagined, in the 
hollows between the papillae. The fluid does not force its way to 
the surface here. Now, this description of a blister will help the 
reader to comprehend the nature of the vesicles and bullae formed 
in disease. Much the same changes are observed in their forma- 
tion as in that of a blister, above noticed. 

So much for vesicles formed by serous fluid only, but now I 
have to speak of those in which inflammatory corpuscles appear 
and play an important part in connexion with the development of 
bullae and vesicles. For example, in small-pox there is at first a 
great increase in the size of the cells of the rete Malpighii, with 
enlargement of the vesicles in the papillae, and subsequently the 
presence of round cells about the vessels, and in the tissue of 
the papillae — this constitutes the papular stage. When the vesicle 
forms, "a layer of elongated cells is observed beneath the 
epidermis (horny layer), and these pass without interruption into 
the obviously swollen cells of the rete Malpighii. Under this layer 
is a network enclosing serum, which is situated nearer the 
epidermis (horny layer) than the corium, and forms the proper 
vesicle. This network is formed by the stretched-out cells of 
the rete, and it encloses the pus cells." The vesicle is there- 
fore chambered into lacunae, and not solitary, each lacuna 
containing perhaps 8 or 10 pus cells (see fig. 8). A number of 
round cells are beneath, and press upon and flatten down the 
papillae. In the pustular stage the pus and round cells increase 
largely. So that in the small-pox vesicle, the disease begins 
as a parenchymatous inflammation of the rete mucosum itself, 
and the pus probably comes from the spindle-shaped cells of 
the rete. The divisions of the vesicle are in its upper parts, and 
formed by the cells of the upper layer of the cuticle. There 
is some difference of opinion about the bulla of erysipelas. Some 
say that the corium and subcutaneous tissues are mainly 
affected and infiltrated with inflammation corpuscles, and no doubt 



34 



VESICLES AND BULLAE. 



that is true, but the epidermis and rete Malpighii are concerned in 
the formation of bullae when they form. Dr. Haight affirms that 
between the corium and the horny layer (see fig. 7) is a network 
of fibres produced by the elongated cells of the rete, forming 
loculi enclosing fluid and exudation cells, which latter are also 
found, as others state, in the deeper parts. But there are 
other vesicles — those of eczema and herpes (see under heads of 
those diseases for illustrations) in which other features are 
found. The changes in these seem to begin in the papillary layer 
itself, and then spread to the rete and epidermis; whilst the 
vesicle is chambered, and not simple. In zona and eczema the 

Fig. 7. 




(Bulla of erysipelas, after Haight. ) 
a. Dilated papilla with vascular coils, b. Rete Malpighii between 
papillae, c. Thicker cords of stretched out spindle-shaped epithelial 
cells, d. Thinner network of spindle-shaped cells, some of which have 
several processes, e. Raised epidermis, to the inner surface of which 
cells of the upper stratum Malpighii adhere. 

papillse seem at first to be increased in bulk by serous exuda- 
tion into them and the formation of exudation corpuscles. 
The fusiform cells of the cutis, according to some, increase in 
number, spread through the rete and the papillary layer, and 
branch and form a complete network, in the meshes of which 
pus cells appear, and thrust aside the normal epithelial cells. Dr. 



VESICLES AXD BULLAE. 35 

Haight found that in herpes zoster, the roof of the vesicle (see 
fig. 17) is formed by several layers of cells pressed flat, without 
nuclei, and not coloured by carmine ; to its under surface 
adheres a layer of flattened but nucleated cells from the Malpighian 
layer, and colouring in carmine. The cavity is divided by 
thick bands into several chambers, which are again penetrated 
by a fine filamentous network. The thicker bands extend per- 
pendicularly between the epidermic layer and that part of the sur- 
face of the corium which lies between the papillae. They con- 
sist of several series of elongated spindle-shaped nucleated cells. 
In each loculus thus produced a papilla projects. The filaments 
passing through these loculi in all directions consist of nucleated 
cells, partly spindle-shaped, partly furnished with processes; and 
also of fine fibres. On the surface of the corium, between the young 
epithelium cells, are here and there cells of another kind, for the 
most part round, and colouring strongly in carmine. In the 
wavy connective tissue of the corium (the papillary layer especially) 
lie a few round granular cells, about the size of white blood 
corpuscles. These cells increase greatly in quantity, and become 
multinuclear (pus) when the vesicle becomes a pustule. The cells 
lying in the corium are prolonged along the blood-vessels into the 
subcutaneous tissue, where they are collected chiefly around the* 
nerves. The nerve fibres themselves are swollen, and the 
axis cylinder lies excentrically (see fig. 18). So then there is a 
multilocular vesicle — the loculi produced by separation and 
stretching of the rete cells — containing fluid and exudation cells, 
which are also found in the papillary layer around the vessels. In 
eczema much the same state of things is present. The vesiculation 
process begins in the papillary layer by a serous catarrh, the 
papillse being filled with serum and exudation cells, the normal cells 
of the cutis being swollen and oedematous ; a notwork being formed 
by the altered and stretched fusiform cells of the rete, and exuda- 
tion cells also appearing in the meshes. The origin of the exudation 
cells and pus cells in zoster, eczema, and variola is still a matter of 
doubt. They may be altered connective-tissue corpuscles, as Biesia- 
decki thinks, or migrated white blood cells escaped from the vessels, 
or they may be altered and proliferating rete cells or their nuclei, as 
Neumann believes. By way of summary I put the matter thus : — 

Vesicles solitary : seat of fluid between strata of 

horny layers of cuticle Svdamina. 

Vesicles solitary : seat of fluid between horny 

and mucous la}-ers Pemphigus. 



Vesicles, or bullse compound : loculi formed by the 
stretched-out cells of the rete 



Variola. 
Herpes. 
Erysipelas. 
Blister. 
Eczema. 



36 PUSTULES. 

Further, in sudamina, pemphigus, and blistering there are no 
inflammatory elements present, but merely the effusion of serum 
and its results, whereas in zona, eczema, and variola, there are 
exudation cells as a primary and essential feature, and these seem 
to be present in the papillary layer and corium. In the first 
two of the three last-named diseases, at the outset, they migrate 
into the rete ; but in the last-named the inflammatory changes 
primarily commence and are originally specially limited to the rete, 
but spread secondarily to the corium. I add a few remarks as 
regards the behaviour of vesicles in general. They are pointed 
and isolated in scabies : confluent in eczema : and discrete, large, 
chambered in loculi, seated on a red base, and disposed in a 
circular group in zona. When they burst they may, if they 
form a patch, give place to " discharge" as in eczema. When the 
cuticle is thick, the fluid does not escape easily. The vesicle may 
appear as a transparent point, deeply-seated in the skin, as seen 
in an affection of the hands called most erroneously eczema 
(see Dysidrosis), in which the perspiratory follicles are dilated and 
gorged with sweat, giving rise to the appearance of the grains of 
sago in a cooked pudding. Yesicles, where the cuticle is thick, 
may fail to burst, and may run into one another, giving rise to 
large blebs. This is a common occurrence about the fingers. 
The contents of blebs vary with the nature of the vesicle. They 
may be sweat or serous fluid, or may contain pyoid and granular 
corpuscles, lymph, fatty matter. The contents in inflammatory 
diseases, at first transparent, become milky, and then opaque 
or purulent, from the development of corpuscular elements. 

BULLAE. 

The bullae, or in reality large vesicles, of erysipelas, herpes, 
and pemphigus, I have spoken of. Bullae occur in the disease 
called rupia, which is syphilitic, and in the syphilitic pemphigus 
are seen especially about the feet and hands of newly-born chil- 
dren. Here the difference is only one of contents, and probably 
not of structure, the contents being stained by hsematin or 
actual blood escaped from the vessels. The papillary- layer is 
implicated in the consequent ulceration. The size of bullae is 
arbitrary. They are tense at first, in consequence of the sudden 
outpouring of fluid beneath the cuticle, but they become flaccid 
presently, from absorption of their contents, and generally, in non- 
syphilitic cases, when the raised cuticle comes away, there is a 
hypersemic surface left, but there is no ulceration, and the cutis 
vera escapes injury. 

PUSTULES. 

Pustules. — These used to be described as elevations of the 
upper part of the derma, produced by pus, quickly formed, and 
coming rapidly to the surface : and as accompanied by more inflam- 



PUSTULES. 37 

mation than are vesicles or papules, and by a deeper affectiou of 
the tissues. Pustules, again, were stated to be primary and 
secondary : in the former hyperemia, together with rapid forma- 
tion of pus occurring, as in ecthyma ; in the latter, the contents 
of the pustule being rather puriform than purulent, the pustules 
commencing as vesicles, the contents being transparent and 
serous, and by-and-by pus being therewith intermingled, as in 
scabies, and even variola and vaccinia, and in eczema impeti- 
ginodes. It was further customary to make three kinds of 
pustules : — (1), psydracious — viz., those which are hard and 
pointed, which have a slightly red circumference, and are often 
seated at the hair follicles ; (2), phlyzacious, which are large, 
raised, vivid red, have an indurated base, and are replaced by thick 
dark scales, as in ecthyma, and (3), achores, a term applied to 
the small accuminated pustules that occur in the scalp : these are 
inflamed sebaceous glands (or boils). But all this is inexact and 
insufficient for the present day. 

Now the remarks which I have made in regard to vesicles and 
their formation, in the case of herpes and variola, will help the 
reader to understand the nature of pustules. In the latter the same 
changes are j)resent in the first instance as in vesicles, only that 
the exudation corpuscles and pus cells increase in number, and 
rapidly as such, and infiltrate the tissues to a much greater extent. 
I may take the pustule of variola for illustration (see Variola, 
chap. vii. S.g. 8) ; when the pustule is produced, the network formed 
by the elongated and stretched cells of the Malpighian layer spread 
deeper and deeper towards the corium, whilst its lacunar are more 
and more filled with pus cells, and these exudation cells, be they 
changed connective-tissue corpuscles or escaped white blood cells, 
surround the papillae vessels in great numbers. It is said that 
there are transitional stages to be observed between the cells and 
the connective tissue corpuscles at the outer edge of the pustule. 

In the network of Malpighian fibres are also found numbers of 
" nuclear bodies, with granular contents and undissolved by acetic 
acid." This is Auspitz's and Basch's account. The umbilication 
of the pustule is due to the tying down of the centre by a folli- 
cular duct. I now turn to the pustule of ecthyma, which is hard, 
has a painful base, and a livid areola, and is the type of what used to 
be called by the exploded term " phlyzacious pustule." Now in it 
the changes appear to commence, according to Prof. Rindfleisch, 
of Bonn * like eczema, by a serous catarrh ot the papillary layer, 
with rapid formation of pus cells in the effused fluid, and the dis- 
tension of the rete by and the collection subsequently in it of the 
exuded fluid and cells, whereas in variola the pus formation com- 
mences in the Malpighian layer or rete mucosum. Of course the 

* Lehrbuch der Pathologischen G-ewebelehre, pp. 234-239. Leipzig: Engelmann, 
1867-9. 



38 SQTJAMiE. 

pustulation in eczema impetiginodes is explained by the formation 
of pus freely and rapidly in the meshes of the stroma, which con- 
stitutes the vesicle, and in the stroma of the papillary layer outside 
and about the vessels, which are hypersemic. In ecthyma the 
localization of the disease is peculiar, and it is just possible that 
it may be shown that the site of the pustule is determined in the 
seat, and by the presence of a hair follicle. The indurated base 
indicates that the inflammation freely invades and affects the 
deeper parts of the corium. Now as to the pustules of f urunculus 
and anthrax, what is to be said ? They are supposed to be circum- 
scribed suppurations of the deeper parts of the corium, together 
with actual death of the central affected parts producing the 
so-called " core." But definite information is needed as to the 
exact nature of this " core." It is not improbable that it is a dead 
or sloughed sebaceous gland. M. Denuce has given good evi- 
dence in favour of this view. There are then pustules that differ 
as regards the primary seat of the pus formation. In variola it is 
the rete : in ecthyma and pustular eczema, the papillary layer. And 
as to the extent of the pus infiltration, it is superficial in eczema, 
deep in severe variola and ecthyma and f urunculus ; and the only 
division of pustules I should make is into large and small, or 
superficial and deep. In a vesico-pustule there are the characters 
of a pustule developing out of those of the vesicle, by an increase 
in the number of pus corpuscles at a later stage. The assumption 
of the characters of the pustule from the first only means that the 
pus cells are produced at an early date. 

SQUAMAE. 

Squamae or Scales. — A few w r ords will suffice to afford a clear 
understanding of their modes of production and the indications 
which they afford of disease. Scales and squamse are of course 
quite distinct from crusts which are formed of dried secretion. 
Scaliness or squamation is of very varying significance and im- 
portance in diseases of the skin. On the one hand it is only an 
accidental phenomenon, and as such accompanies all diseases in 
which the skin is inflamed or hypersemic, and on the other it 
may constitute the essential disease • present. As regards the first 
condition, whenever the nutrition of the cutis is seriously dis- 
turbed, the epithelial formation suffers. The cells of the cuticle are, 
likewise, imperfectly formed, and are rapidly thrown off. This 
is the case in erythema, however produced ; in the acute specific 
diseases, especially scarlet fever and measles, in which the cuticle 
dies, as it were, in consequence of the operation of the poison, 
and is thrown off to be reproduced: at the fag end of all inflam- 
matory diseases, as herpes and eczema, when the cuticle before 
destroyed by vesiculation or pustulation begins again to re-form, 
but to re-form imperfectly, in consequence of the disease and 



SQUAMA. 39 

hyperemia of the cutis which still persists ; and in the disturbance 
resulting from the attack of fungi, as in tinea versicolor, tinea 
tonsurans. In syphilitic disease and in lupus, where the deposit 
or growth of new granulation tissue has not destroyed the rete or 
horny layer, there is disturbed formation of cuticle, in part the 
result of the hyperaemia present. So in other diseases scaliness is 
at some part of their course an accidental occurrence. 

But there are on the other hand, as before observed, several 
diseases in which one of the characteristic features is the free pro- 
duction, collection, and shedding of epithelial scales. These 
diseases are psoriasis, pityriasis, and xeroderma with its exaggerated 
condition ichthyosis. In psoriasis the cells of the whole epidermic 
horny layer, and of the rete are largely increased, and cells like 
altered rete cells abound in the papillary layer around the vessels, 
the papillae themselves being greatly hypertrophied, and their vessels 
engorged. There are no exudation cells. The disease might aptly 
be described as an over-growth of epithelial cells. The collection 
of cells on the surface is an evidence of this, and these scales have 
pits on their under surface that receive the enlarged papillae. 

Pityriasis — that term being used to denote simple hypershed- 
ding of cuticular cells, generally depends on simple hyperemia, but 
sometimes as in pityriasis rubra, the hyperaemia being marked and 
extensive, the shedding of scales — or flakes rather, for the scales 
become flakes — is also marked and extensive. Pityriasis or epithe- 
lial desquamation needs to be distinguished from mere seborrhcea, 
in which small fatty plates, formed from an excessive secretion of 
sebum, are present. There is a "fatty," in addition to an epithe- 
lial scaliness. In xeroderma, the horny layer of the cuticle is 
greatly hypertrophied as a congenital condition, the entire skin 
being likewise thickened. In some cases the sebaceous glands 
furnish a certain quantity of sebum, and this matted together 
with epithelial cells into plates, gives rise to ichthyosis, or fish 
skin disease. It is very probable that whenever desquamation takes 
place, some physical change in the thrown-off cells has happened. 

Rindfleisch I think it is who says that the formation of cells 
is so rapid that they have no time to become adherent. But M. 
Ranvier* questions this, and on the ground that it is not the deep 
layers of the cells that are thrown off, nor does desquamation occur 
directly after their formation. That is to say, neither seat nor time 
of desquamation countenance Pindfleisch's view ; and M. Ranvier 
declares that when desquamation begins the nucleoli of the horny 
cells of rete mucosum dilate, and so a modification of the cells 
is produced. The horny deposit does not make its appearance, and 
the cells remain in a softened condition, the cells in fact undergo 
a mucous transformation, and so are thrown off. 

Speaking generally of scaliness then, it may be said that it is fatty 

* Du role que joue la tranforination vesiculeuse de nucleoles dans la desquama- 
tion de la peau, Gas. de Biologic, 1869. 



40 TUBERCULA. 

or purely epithelial ; that' it is accidental and secondary to other 
diseases, or a primary and an essential part of the disease present. 
In xeroderma it is seen as a congenital defect, in psoriasis as part 
of a general hypertrophy of the epidermis and papillary layers, and 
in desquamation as a direct result of hyperemia, the two latter con- 
stituting pityriasis. In pityriasis in its simple form it is a throw- 
ing off of branny scales, and in pityriasis rubra of flakes, and in 
psoriasis the scales are heaped together, superimposed the one upon 
the other, into white silvery thick masses, especially about the 
elbows and knees where the cuticle is thick. In some cases of 
scaliness the scales are loaded with the spores and threads of fungi 
on their under surface, as in pityriasis versicolor ; the scales being 
given off as a branny desquamation, and the patch having a fawn 
colour. Simple pityriasis is accompanied by itching, and heat 
to a slight degree. Sow and then the epidermis is thrown off in 
large lamellar pieces as from the hand and foot, which seems to 
result simply from hyperemia. This is rare. 

Now I want to add one word about scaliness as it is seen in 
syphilitic eruptions. It is said that in these the scales are few 
and adherent. Neumann, for instance, gives the diagnosis between 
psoriasis vulgaris and syphilitic psoriasis thus : " In the first there 
is a great mass of scales of a shining pearly appearance, loosely 
attached to the substratum, and when removed showing a bleeding 
corium: in the second the mass of scales is small, of a dirty 
whitish colour, closely adherent, and on removal showing a pale- 
red infiltration of the corium." ]S T ow I contend that though the 
one condition is rightly termed psoriasis vulgaris, the other is 
wrongly termed psoriasis syphilitica. The essence of the one is the 
hypertrophied growth of the rete cells and the papillary enlarge- 
ment. The essence of the other is a new formation of granulation 
tissue, which, though it so far disturbs the nutrition of the 
epidermis as to give rise to scaliness, and so gives rise to the 
appearance of psoriasis, yet involves rather a diminished formation 
of epidermis — the opposite condition to that seen in psoriasis. 
The same thing is seen in lupus ; if the new growth only deranges 
but does not entirely overwhelm and prevent the formation of 
epithelium, there is slight scaliness over the lupus patch, and to 
this state of things the term lupus-psoriasis has been applied. 
There is no psoriasis at all present. There is a diminished — though 
disturbed — production of cuticular cells, and there is no hyper- 
trophy of the papillary layer. There is a thin layer of cells on 
the granulation tissue, but it is deceptive. It is not the cuticular 
hypertrophy that is of moment, but the growth of new granulation 
tissue in the cutis. 

TUBERCULA. 

Tubercula. — By the term tuberculum Willan meant any lump 
or large pimple not defined by the term papula. He said a 



TUBERCULA. 41 

tuberculum is "a hard, small, circumscribed and permanent 
tumour suppurating partially." Little fleshy lumps would roughly 
describe tubercula. Now of course little lumps are formed under 
a variety of conditions in the course and cure of diseases — as in ci- 
catrizations, enlargements of glands, as in indurated acne, dilatation 
of the sweat and fatty glands, in cysts, and so on ; but these are not 
essentially primary, but mostly accidental conditions connected 
with special diseases. The term tuberculum should be applied to 
primary lumps formed of new tissue — new growths — in and from 
the skin ; and in that sense it is applicable to fibrous outgrowths of the 
connective tissue {homoplasms), including molluscum fibrosum or 
fibroma, keloid, frambcesia, to growths of new granulation tissue 
(neoplasms), as in lupus, syphilis, leprosy, cancer, and rodent ulcer, 
and to strumous disease of the skin. So then it will be evident that 
tubercules or tubercula occur as a primary condition in those 
diseases which are essentially characterized by new growths in and 
from the skin. The diagnostic features of the several tubercula 
are to be found in the specific characters of the tubercula them- 
selves, and the changes they undergo together with the nature of 
concomitant phenomena. I will therefore give the pathological 
features of these several tubercula and anticipate to some slight 
extent what I have to say under the head of general diagnosis as 
regards concomitants, because I think some very important lessons 
may be missed if I divorce altogether the local from the general 
phenomena. 

And first of simple hypertrophies, or simple fibrous growths 
of the skin. Warts I do not refer to particularly. First there 
is fibroma or molluscum fibrosum, which disease consists of 
outgrowths of the integumentary structures — the fibro-cellular ele- 
ments of the cutis — which push before them the most superficial 
parts. These fibromata at the beginning are small, but they increase 
to any size ; and they have this characteristic feature, that they 
look and feel like ordinary intergument; as they enlarge they be- 
come pedunculated. They feel soft and lax ; and look as the skin, 
white. A man may have his whole body covered over with these 
tumours, of most varying size. The minute pathology of the 
disease is an hypertrophous growth of the fibro-cellular tissue of 
the skin, and especially that part which forms the dermic layer of 
the hair follicle. In keloid there are tumours formed by hyper- 
trophy of the connective tissue of the corium originating around 
the tunica adventitia or external coat of the arterioles of the skin, 
in which elastic fibres are abundant. It forms raised, well- 
defined tumours, of a pale colour at first, and then pinkish with 
vessels running into them ; and possesses this pecularity, that the 
new growth contracts at the edge and puckers the integuments 
about it so as to induce distortion. It is this contractibility that 
is characteristic of keloid. The papillary layer and epidermis are 
unaffected primarily. Keloid occurs as an idiopathic disease, 



4:2 TUBERCULA. 

• 

or it arises in the seat of wounds of all kinds, in whose cicatrices 
grow hard fibroid nodules of greater or less extent. It is not a 
common disease. The main difference between keloid and scar 
tissue is that in the former the fibres run in bands, parallel to the 
skin, whereas in a scar they form a felted network. Another 
disease in which tubercles are present is framboesia, but this is a 
very rare and an exotic 'disease, and so I need not dwell upon it 
here. 

I therefore pass to consider the characters of those tubercular 
formations which are made up of new kinds of tissue 
(heteroplastic), and are of such common occurrence in the 
diseases lupus, syphilis, cancer, rodent ulcer, and leprosy. In 
the two former and in the latter — viz., lupus, syphilis, and 
leprosy, the disease originates in the true skin, and the tumour- 
like masses form a link in regard of intimate structure, inter- 
mediate pathologically speaking, between inflammatory products 
on the one hand, and real tumours on the other. They are dis- 
tinguished by Virchow, as granulation tumours — the tissue of 
which they are composed being called granulation tissue, and this is 
believed to take its origin from the connective tissue, whereas, in 
cancer of the skin, that is, eptihelioma and rodent ulcer, the 
disease originates in disorder of the epithelial tissue elements. The 
granulation tissue is made up of cells like lymph cells, which are 
the connective tissue corpuscles arrested in their growth according 
to Virchow, or actually escaped white blood or lymph cells accord- 
ing to others, enclosed in groups in a network of fibres. The 
peculiarity of this cell growth consists in the permanent con- 
tinuance of the new formed elements in the granulation stage, 
in the fact that it does not undergo further development, and 
lastly, in the abruptness of its passage from the granulation stage 
to one of degeneration, leaving atrophy behind. If there are no 
marked differences in the minute anatomical characters of the 
granulation tissue, there are in the coarser features, and in the 
behaviour of the actual tubercular formations themselves in lupus, 
syphilis, and leprosy, and these I shall state, though I admit the 
concomitant conditions are our chief guide to diagnosis. Now in 
lupus the tubercles are soft and vascular in the mass, more so than 
in syphilis, being made up of peculiarly immature cells probably. 
The cells tend to migrate widely and deeply, hence the tendency of 
the disease to quickly spread. These cells undergo degeneration 
easily, and hence the rapidity with which ulceration is wont to 
occur. So then the tubercles of lupus are soft and vascular. 
They have a gelatinous aspect, which is characteristic, and they are 
reddish; and there is one more point to notice about them — viz., 
they do not occur in a scattered form around a main patch, and 
they are covered by few thin and adherent scales, whilst the sur- 
face does not, when ulceration sets in, discharge so very freely or 
greatly crust. These characters contrast with those of syphilis, 



TUBEECULA. 43 

the tubercula of which are less vascular, and therefore paler. 
Composed of cells perhaps more closely packed together, and of 
more', fibres, they lack the gelatinous aspect of the lupus tu- 
bercles, and I would add, they occur in tbe scattered form, a point 
to which I attribute great diagnostic importance. When they 
ulcerate there is free discharge, and large green purulent dark 
crusts form freely. The tumours of Elephantiasis Grsecorum are 
more like those of lupus, being very rich in cells. They have 
this peculiarity that they do not tend to soften up, and , dege- 
nerate so rapidly as in the other granulation tissues of lupus 
and syphilis. Now I may just observe, that in lupus there is 
no evidence of disease in the form of related constitutional condi- 
tions or other phenomena. This is altogether different from the 
case of syphilis and Elephantiasis Grsecorum, and though one 
may sometimes be able correctly to diagnose lupus from syphilis 
by the mere characters of the eruptions in these diseases, yet as the 
rule, one is guided by an examination of the related phenomena, 
which show that syphilitic tubercula form only a small part of 
the existing disease. In scrofula livid red soft tumours, which 
soften up, suppurate, and give place to ulcers, are formed. These, 
however, exhibit the behaviour of inflammatory products, and can 
be at once distinguished from lupus. 

In the idsease known as the elephant leg, the Elephantiasis 
Arabum, Barbadoes leg, or pachydermia or bucnemia tropica, 
nodules are formed in the skin, which is generally indurated. 
Here there is no granulation tissue, but merely fibroid infiltration 
of the corium, and subcutaneous cellular tissue, the result of 
lymphatic oedema. 

Now as in lupus, syphilis, and leprosy the real seat of the 
disease is the true skin, its deeper part : so in cancer and rodent 
ulcer the essential seat of the disease is the epidermis, as it would 
really appear from recent observation, of the lymph vessels of the 
skin. The tubercle of epithelioma as affecting the lip, the scrotum, 
and the vulva is at first "a little lump under the skin, flattish, 
hard, and slightly tender, its surface becoming slightly dark or 
red, and slightly moist, and presently, perhaps, scabbed or 
cracked, the induration extending at the base, and ulceration 
setting in at the centre of the lump." The ulcerated surface is 
generally papillated in appearance, and covered by a dirty ichor. 
The edge is hard, and presently everted and undermined. If a sec- 
tion of the mass be made, it has a greyish aspect, tinged with yellow 
at times, and on microscopic examination a stroma formed by the 
connective tissue of the skin is found, containing vessels ; it is best 
seen in the deepest part of the tumour — forming a network in 
which are embedded bodies and parcels of various sizes and 
arrangements, made up of epithelial cells. These will be fully 
described in speaking of cancer. Rodent ulcer begins, as 
does cancer, by a small hard pimple, which runs a very slow 



44 SECONDARY CHANGES. 

course to ulceration. It also scabs. The surface of the ulcer 
is clean, it shows attempts at repair now and then, the edge is 
hard, but not undermined or everted. There is no surrounding 
induration or gland implication. A section of the tubercle is 
firm, grey, and fibrous. The minute characters are the same 
as in epithelial cancer, save that there is more fibrous stroma, 
and the globular bodies and epidermic capsules are less in 
amount. 

SECONDARY CHANGES. 

I mentioned in enumerating the several varieties of elementary 
lesions that these were followed by certain secondary changes, 
which demanded special notice on account of their beiug in some 
degree important in a diagnostic point of view. These secondary 
changes are desquamation, excoriations, crusts, stainings, ulcera- 
tion, scars, and so on ; and I have incidentally, in speaking of 
elementary lesions, noticed some particulars, but will now make 
some special general remarks about them. 

1. I need say no more in regard to desquamation than what I 
have said under the head of squamae. 

2. Crusting. — This occurs wherever there is discharge or suppu- 
ration. Crusts, of course, are not like scales, except in ichthyosis, 
made up of epithelial matter, but of inflammatory products, 
including pus cells in greater or less quantity. Crusts cannot be 
marked among the primary phenomena of disease ; they occur in 
the later stages, and subsequently to primary changes. But there 
are two classes of cases I may make. In one crusts form in con- 
nexion with sero-purulent secretion without ulceration, in the other 
they are consequent upon distinct ulceration. In regard to the 
first class, if there be actual discharge the crusts will be freely 
formed. If the discharge be mainly serous, they are thin, light, 
filmy crusts, as in impetigo and simple eczema ; if the discharge be 
mainly purulent, they are thicker, yellow, and distinct crusts, as in 
eczema impetiginodes. The very free formation of purulent crusts 
in young or old, which is not explained by inflammation of great 
intensity, is indicative of the presence of a pyogenic habit, or what 
is almost synonymous, the strumous diathesis. This is a point of 
the greatest practical importance. Crusts will be reproduced when 
cast off if the discharge continues, as in eczema ; and but once 
formed or not continuously re-formed, if the discharge is of tem- 
porary duration, as in herpes. They will be large and irregular 
if the discharge occurs over a wide area as in eczema, or small and 
circumscribed if the vesicle or the pustule is solitary and distinct, 
as in ecthyma, furunculus, and sycosis. They will be more ad- 
herent when the pns does not actually escape from the skin, but 
is confined before it dries up, as in ecthyma and furunculus, than 
where it is freely poured out, and escapes from the skin freely upon 
the surface. They will be dark and discoloured where sanious 



SECONDARY CHANGES. 45 

fluid is mingled with the secretion, as in rupia (which is syphilitic) 
and ecthyma cachecticum. In regard to the crusts forming as a 
consequence of ulceration a word or two must be said. It is in 
inflammation connected with cachexia and the softening up of the 
skin connected with certain diathetic states that these crusts are 
observed. Yery rarely a simple inflammation, ex gr. ecthyma in 
a bad nourished person may go on to ulceration, and then there 
are discharge and crusting, but the crusts are flattish, and it is 
easy to see from what cause they arise. The seat of ulceration 
is often in the legs, where the influence of varicose veins and 
gravitation helps out the ulceration. But there are other cases in 
which there is no cachexia in the sense of mal-nutrition, where 
ulceration and subsequent crusting are to be accounted for by 
some specific influence of a constitutional kind, and here there are 
two classes of cases. The ulceration may be preceded by certain 
elementary lesions, tubercula, which naturally tend to ulcerate, 
and no difficulty occurs in diagnosing between lupus, cancer, 
syphilis, rodent ulcer, and the like, as the rule. The crusts in 
these cases are peculiar. But there is another class in which an 
ordinary skin affection, not usually prone to ulcerate and crust, does 
so exceptionally ; and then one must decide from the nature of 
the crusts, etc., what the exceptional influence at work is. First of 
all, as to the differences of the crusts of lupus, syphilis, cancer, 
rodent ulcer, and struma. Those of lupus are generally flat and 
adherent, and not specially dark-coloured ; they are, moreover, 
not free in proportion to the amount of tissue change. On the 
other hand, in syphilis the crusts are adherent ; they are dark- 
coloured, and free oftentimes in proportion to the amount of the 
tissue changes ; and what is of importance, they are made up of a 
good amount of pus and sanies. Rodent ulcer does not crust when 
the disease is marked, though it tends to cicatrize : and in cancer 
there is often slight scabbing. This all means that there is little 
discharge in lupus and cancer, none practically in rodent ulcer, 
and often a good deal in syphilis. Given a case of what looks so 
like lupus and syphilis that the diagnosis is difficult and there be 
free scabbing, one may decide in favour of syphilis, particularly if 
the crusts be dark, which implies that sanious fluid has been 
poured out. The cockle-shaped crust is diagnostic of syphilis. 
It is produced by the drying of successive yieldings of sanious 
pus pushing forward successively. I now turn to the other class 
of cases, to which I referred as one in which crusts form under 
exceptional circumstances so as to constitute an unusual feature ; 
for example, a case of psoriasis is complicated not by very free 
scaliness, but crusting : or an eczema by the formation of scabs like 
the bark of a tree — hence the term eczema scabidum. There are 
two things that may account for this, the presence of the strumous 
diathesis, or a syphilitic taint, and one must decide by the history 
of the disease and patient, his general aspect and concomitants. 



46 SECONDARY CHANGES. 

Crusts, it must not be forgotten, are formed sometimes solely of 
sebum exuded in larger quantities, then they are flat, dirty white, 
greasy and " stuck on." But crusts may be made up likewise /of 
parasitic fungus as in f avus, when the crusts are dry, brittle, and 
light sulphur-coloured, and their lupine shape is almost pathog- 
nomic. 

3. Ulceration. — This depends of course upon the destruction of the 
true cutis. How is this destroyed ? By inflammatory action if it 
be severe and pus formation extensive and involving the cutis ; 
bv infiltration of the true skin by new products (that take the 
place of the normal products), and the degeneration of these pro- 
ducts, as in cancer, syphilis, lupus, leprosy, scrofulous disease ; 
and by the softening up and decay of the normal tissues through 
sheer want of nutrition, especially after traumatic injury and con- 
gestion, as in the leg. These are practically the three sources of 
ulceration in skin disease, and they may be more or less inter- 
mingled — ulceration from simple inflammation is not common, 
and only common where there is cachexia ; its nature is not diffi- 
cult to recognise. But as regards the ulceration of lupus, syphilis, 
and cancer, there are differences. Dr. Auspitz, speaking of lupus 
ulceration, says " the appearances do not differ essentially from 
those of other forms of ulceration. If the rete Malpighii is not 
completely destroyed and thrown off, its elements are found in a 
state of fatty degeneration, and at spots transformed into mole- 
cular masses. The limits of the papillae towards the rete may be 
seen to be already indistinct, whilst the granular detritus and 
suppuration are already appearing in the tissue of the cutis : in 
the deeper layers of the cutis, here and there local, limited areas 
of fatty degeneration of the new formed tissue elements are to be 
seen. If the molecular destruction is further advanced, finally 
there is a loss of substance covered over by a thick brown crust, 
and extending more or less deeply into the tissue of the cutis. 
The base of the ulcer consists of growing granulations, consisting 
of cells of the cutis growing forward and covered with an abun- 
dant pus, whose elements present nothing of a specific character. 
Neither the pus, nor the base of the ulcer, nor its limitation and 
form presents any characters distinguishing it from other ulcera- 
tions arising in similar conditions." This gives a very good idea 
of the general characters of ulceration in the cases under notice. 
If there are no differences in mere minute aspect there are in 
concomitants and the course of the disease. As regards the 
ulceration itself, when that occurs, in lupus it is superficial gene- 
rally speaking, and rarely deep ; the surface is also red, slightly 
mammillated, quasi-gelatinous, smooth, covered by a thin exuda- 
tion. The edges are thick and inflammatory, not undermined, not 
everted — that is, there is little pus formation, the tissue simply 
degenerates and atrophies. In syphilis it is foul, dirty, sloughing ; 



SECONDARY CHANGES. 47 

there is a good deal of pus formation ; this is accompanied by a 
copper-coloured areola, and sharply-cut edges, that are everted 
slightly. In cancer the ulcer is papillated, the edges everted, 
undermined and hardened, the surface is covered by a foul ichor. 
Rodent ulcer is clean and without ichor, but rugged whilst the 
ed^es are hard, sinuous, and abrupt in both directions. The only 
difficulty lies between lupus and syphilis, because with the others 
there are generally other characteristic concomitants. But given 
lupus or syphilitic ulceration, and a difficulty in diagnosis, I 
would say if there be free ulceration and free crusting as com- 
pared with the amount of deposit, it is more likely to be syphilis 
than lupus. I repeat •that when an inflamed surface occurs, 
and it undergoes little change for a long time, and then it ulce- 
rates with or without crusting, and this is apparently unaccounted 
for by the mere inflammation, the case is probably one of syphilis, 
unless a marked strumous history can be made out, or a strumous 
habit of body. I am in the habit of saying, if a patient comes 
before me with a red inflamed patch, and there be ulceration, 
that the disease is either lupus or syphilis ; if there be but 
one patch, lupus ; if many, and scattered, syphilis. The con- 
comitants help one further of course. That is to say, the 
two common ulcerating diseases of the skin are lupus and 
syphilis. 

4. Excoriations. — All I need say about these is, that their seat 
is often very suggestive. If they are about the front arms, they 
are probably the result of scratching practised to relieve the itch- 
ing of scabies. If they are about the clavicular and scapular 
regions they are almost sure to be the result of scratching to 
relieve the irritation set up by pediculi. In impetigo contagiosa 
the scratches made by the patient " fester " rapidly. 

5. Sca?*s and local atrophies are important. They follow ec- 
thyma when severe, variola, herpes zoster, furun cuius, anthrax, 
pustula maligna, syphilitic lupus, and strumous ulceration, and 
the absorption of tubercles without ulceration. The seat of 
scars in tke two first is suggestive. They are very small in ec- 
thyma, and in syphilis and lupus ulceration they are more or less 
extensive ; but there is this difference, that they are multiple in 
the former and not in the latter, as the rule. A distinct scarring 
in spots larger than would be produced by ecthyma or furunculus, 
and in more than one place in the body together, and not the face 
in one spot only, say the leg and arm, not in the seat of a gland 
— for then it may be strumous, is very suspicious of syphilis. 
Loss of substance without ulceration is often seen in lupus and 
syphilis ; the difference in the scars depends upon the extent of 
tissue destroyed ; for in the atrophy without ulceration, neither 
the papillae nor glands need be destroyed. Old scars of an exten- 
sive kind mean then practically syphilis or lupus. If multiple, 



48 SECONDARY CHANGES. 

syphilis ; if solitary and on the face, lupns. This is a rough 
guide to diagnosis. Those who wish to know more about the 
philosophy of scars may consult a paper by Dr. Swerchesky, on 
the "Physiology and Pathology of Scars," treating of the me- 
chanism of scars, including an account of the laws of cicatrization, 
cleavage, etc., published in the July, 1871, number of the American 
Journal of Syphilogrcvphy and Dermatology, and continued in a 
later issue. 



CHAPTER IT. 

ETIOLOGY— CAUSES OF BLOOD, TISSUE, AND NERVE CHANGE- 
INFLUENCE OF AGE, SEX, FLANNEL, SCRATCHING, ETC.— CONDI- 
TIONS WHICH DETERMINE THE LOCAL DEVELOPMENT OF DISEASE. 

Now in the last chapter the general appearances of diseased 
changes in the skin were discussed. It is now necessary to indi- 
cate more distinctly the causes of these changes. 

The reader will remember that in the introductory chapter I 
laid great stress upon the necessity, in studying skin diseases, 
of trying to determine in what tissue any given disease originated, 
whether it be in nerve, blood, cell, or lymphatic. I consequently 
think it best to arrange the causes of diseases of the skin accord- 
ing as the} 7 seem to operate upon and through or originate in, 
disorders of these respectively. 

In order that nutrition may be healthily carried on in any part, 
there must be — (1) a proper state of the blood ; (2) a proper con- 
dition and behaviour of the tissues to be nourished ; and (3) a 
right exercise of the controlling influence exerted by the nerves. 
And these three must work harmoniously together. Deviations 
from health may originate consequently from a flaw in any one of 
the three conditions above named. The theoretical origin, there- 
fore, of diseased changes in the skin may be specially in the 
blood, as we see in zymotic affections, and here the skin affection 
is only symptomatic or part of a more general disease ; in the tissues 
themselves, as seen in the case of warts, cancer, keloid, psoriasis ; 
or in the' nerves, as in pruritus, and, it is thought and now 
generally taught, herpes, pemphigus, and urticaria. If the exact 
origin of disease be not as stated, the parts of the system chiefly 
concerned in the production of diseased conditions may be em- 
phatically in one case the blood, in a second the tissues, and in a 
third the nerves. But of course, inasmuch as the ordinary action 
of these three agencies is bound up and related in the closest 
manner in health, the misbehaviour in disease of one affects 
secondarily, the proper action of others of the three agencies 
concerned in healthy nutrition. So that all are more or less 
involved in disease when fully developed, but primarily one or 
the other is mainly concerned in it 

ISTow there is much readiness to ascribe disease to changes in 
the blood, but not to sufficiently recognise the influence of per- 
4 



50 ETIOLOGY. 

versions in the inherent cell-life of the skin structures, nor the 
controlling supervision of the nerves in the generation of cutaneous 
disease. If I am asked for an example of disordered tissue-life, 
I should give that of cancer; the local tissue changes are not 
sufficiently explained by any alteration in the blood current. There 
is no appreciable disorder of it. That is secondary to the cell pro- 
liferation, which is the essential disease in the early stage. Take 
keloid again — hypertrophous growth of the fibro-cellular tissue of 
the skin, is the only thing to be detected ; it is apparently primary. 
These are examples of deviations from the normal cell-life of the 
skin, at present explained by no blood cause ; by nothing save a 
change originating in the tissues. 

So is it in some degree with the nerves. It is probable that the 
origin of some diseases of the skin may really be in the central 
nervous system, and the cutaneous trouble is the effect of a general 
disturbance of the nervous system ; or in the nerves themselves 
that run to the affected part ; at any rate the nerves are mainly 
concerned, or they constitute the agency by which the morbid 
changes in the skin are produced. No one doubts that herpes re- 
sults from irritation of the nerves going to the seat of eruption. 
It is true that the nerve disorder which seems to be primary, may 
result from a blood change, but we know that it may also arise 
from a local impression. Each day pathology is more fully proving 
the neurotic origin of certain cutaneous diseases. 

There are then three main ways in which the nervous system 
may act upon the skin (in addition to altering its sensibility, and 
through reflex action), first by inducing changes in the calibre of 
the vessels, and so influencing the transudation of fluid ; secondly, 
it would seem by encouraging an hyperactivity in the cell-life ; 
and thirdly, where there is general debility there is lessened 
nervous control over tissue, the reparative process is not so active, 
and the skin cannot resist so well as it should external influences 
that tend to injure it, or induce disease. 

But it would seem that not only are blood, tissue, and nerve 
collectively and individually involved in the production of patho- 
logical results as regards the skin, but also the lymphatic system. 
This, however, one would imagine, from the little notice taken of 
it by the physician, is a thing out of place and of no service. My 
reasons for thinking that changes in the fibro-cellular tissue and 
disorder of the lymphatics are related, will be stated under the 
head of hypertrophies and atrophies, in speaking of keloid, 
scleroderma, and their allies. 

I have thus far generalized so as to enable the student to com- 
prehend in some degree the general sources and nature of the 
changes that occur in skin diseases, and to show that in different 
morbid processes, disorder of the blood in one, of the tissue-life in 
another, and of the nerves in another, are principally concerned as 
causes of mischief. 



ETIOLOGY. 51 

Having thus stated the three main channels through which 
" causes " act, I may now give a summary of the more generally 
recognised influences that induce blood, nerve, and tissue changes, 
and I especially enumerate the causes that produce 

(A.) Altered States of the Blood-current. They are — 

1. Poisons of acute specific diseases — ex., those of small- 

pox, scarlatina, rubeola, &c. 

2. The circulation of special poisons, be they animal — ex., 

syphilitic: medicinal substances — e.g., arsenic, bella- 
donna, copaiba, nitrate of silver, -bromides : or diete- 
tic, such as shell-fish, giving rise to urticaria, roseola, 
erythema. 

3. Dietetic errors, as in wine-drinkers, high livers, non- 

vegetarians, &c, leading to the increase of urea and 
uric acid in the blood. 

4. The tuberculous, scrofulous, and lymphatic dyscrasise, 

giving rise to non-specific eruption — ex., impetigo, acne. 

5. The gouty and rheumatic diatheses, as in lichen agrius. 

6. Altered and lowered nutrition from such causes as bad 

living, poverty, misery. 

7. The accumulation of excreta in the blood from non- 

excretion, suppression of natural discharges, kidney 
disease, &c. 

8. Convalescence from severe and lowering diseases by 

which the body is rendered much less able to resist 
disease. 

9. Climacteric, or endemic influences, often malarial in 

nature, which act by deteriorating the system generally, 
and give rise to the frambcesia of the West Indies, the 
sibbens of Scotland, elephantiasis and its allies, the 
pellagra of Lombardy, the bucnemia, or Barbadoes 
leg, the Aleppo evil, and Delhi boil, the carate of New 
Granada, &c. 
10. Disorders of the liver and spleen leading to pigmentary 
deposits in various parts, jaundice, and pruritus, &c. 
(B.) There are certain states of mal-nutrition in which disordered 
tissue-life seems to be the prominent feature. The causes of some 
are unknown. Local irritants, however, frequently lead to altera- 
tions of tissue, and rank here with burns, scalds, parasites, the 
occupations of bricklayers, masons, and washerwomen, etc., as 
causes of local mischief. 

I have seen dyers, and those who handle cheap clothing, suffer 
from erythemata due to the irritant action of dyes. 

I believe that certain tissue peculiarities may be inherited. 
The father may transmit dispositions in tissues to behave in 
particular ways directly to the child, as a local peculiarity, in- 
dependent of any blood state, and in this sense psoriasis, cancer, 
ichthyosis, may be hereditary. 



52 ETIOLOGY. 

In this place must be mentioned parasitic fungi as disturbers of 
local nutrition. 

(C.) Influences that play upon the nerves. Oftentimes the nerves 
are morbidly excitable, as in urticaria. All causes of debility tend 
to perverted innervation, but as a rule local irritants are those 
agencies that induce nerve disorder, which leads to diseases in the 
skin. Ex. : "Want of cleanliness ; alternations of temperature ; 
undue exposure to the sun ; the action of ordinary local irritants ; 
occupation involving special causes of local irritation, as in 
cooks and firemen,' who are constantly exposed to great heat. 
Then chronic visceral disease may be reflected through nervous 
agency to the skin, and so uterine, gastric, and intestinal affec- 
tions, often give rise by " sympathy " to chrouic congestion of the 
face and other cutaneous disorders. 

.Now it is remarkable that the two leading dermatologists of 
the day — Wilson and Hebra — should totally disagree in regard 
to the comparative influence of the two great groups of causes, 
general and local. Hebra is the advocate of the local origin, the 
idiopathic origin of skin diseases ; Wilson of the reverse doctrine. 
Hebra says, "much more potent in the generation of disease of 
the skin than the internal causes that have their seat in the organ 
itself, are those agencies which are external to the body, and which 
affect the skin directly ; thus are produced the so-called idiopathic 
dermatoses." Among the external causes which Hebra enumerates 
are climate, clothing, occupation, mode of life, atmospheric con- 
ditions, unwholesome handicraft, pressure, friction, contusion, 
scratching, neglect of cleanliness, too frequent or too energetic 
washing and bathing, irritants used for medical purposes, such as 
rubefacients, epispastics, the moxa, &c, and epiphyta, dermatozoa, 
and epizoa. 

Now, in the instances of handicraft, pressure, friction, and 
uncleanliness, Hebra can best establish his point ; but even here 
it is not the healthy mechanic who gets his skin disordered, but 
he who has been debilitated, or who is "out of work," or is 
disordered by bad living, or drinking habits, or the like. 

The local cause is the excitant of the disease, rather than the 
sole producer, in many of these cases. He certainly cures most 
rapidly who looks after the general state of health, removes blood 
impurification, and tones up the body. But who will say that 
parasitic disease is entirely local? There is surely a general 
condition of nutrition which must be present before fungi will 
flourish. 

In the majority of cases there is a predisposed state of system, 
and the actual disease is evoked by local agencies, and these, as I 
have said, act frequently through the nerves of the affected parts. 

There are two sources of local irritation that deserve specia. 
notice. I refer to the use of flannel worn next the skin, and 
scratching. Oftentimes the simplest and most commonplace 



ETIOLOGY. 53 

agencies, harmless in health, become active agents in the intensifi- 
cation of diseased conditions of the skin. This is the case with 
the wearing of flannel next the skin. It is scarcely necessary to 
say that some skins are so irritable in health as to be excited to an 
unbearable degree by the use of flannel. If this be so, then, when- 
ever there is a tendency to exaltation of the sensibility of the skin, 
this may not only be heightened by the irritation of flannel, but 
the latter may give rise to decided physical alteration. In a very 
large number of cases of skin disease pruritus is in this way 
intensified and the disease even protracted, and in proportion to 
the degree of uncleanliness. Flannel acts, as a mechanical irritant, 
by augmenting the local heat, and intensifying reflex action. 
When, therefore, a congestive state of the skin, or any disposition 
to pruritus exists, the flannel should be taken off from next the 
skin, and placed, if necessary, outside the linen ; — this will prevent 
any " catching cold." The diseases in which this is advisable are, 
chiefly — erythemata, roseola, urticaria, certain syphilodermata in 
their early stages, scabies, and prurigo. A remembrance of this 
little practical point will sometimes give us the greatest cause to 
be thankful that we attended to it, trifling though it be. 

Scratching plays an important part in the modification of skin 
diseases, most of which are accompanied by itching. To relieve 
itching, scratching is the natural topical application. What does 
it do ? 1. When there is no eruption, it may produce one. For 
example, in pruritus, it gives rise to excoriations, an artificial 
eczema, general enlargement and turgescence of the follicles of the 
skin, with, perhaps, abrasion of the cuticle over and above them ; 
wheals in a nettle-rash subject ; ecthymatous pustules in the ill- 
conditioned. Of course in all. these cases there is a basis to go 
upon — a tendency to the several diseases produced. I scratch a 
healthy person, and the local injury is soon remedied. 2. It 
augments and modifies existing eruptions. I see in eczema how it 
inflames, and increases the discharge and subsequent crusting; 
in lichen, the thickening of the derma. In scabies it gives rise 
to the peculiar " scratched lines " so suggestive of the disease, 
and many of the ecthymatous pustules ; in prurigo, the peculiar 
ecchymosed apices of the papules, and helps out the coarse urtica- 
tion. 3. When the disease is non-contagious, secretion, in scratching, 
may be transferred from place to place ; and if acrid, set up local 
inflammation ; and when contagious, scratching is the surest method 
of inoculation, as in the case of contagious impetigo. Children 
in this way transplant the disease from the head to various parts 
of the body. Mothers, beyond a doubt, get the disease about their 
hands from contact with children. 

Kow some of the above-named causes of skin diseases have 
been called ephemeral, such as in the acute specific diseases ; some 
persistent, as in lichen, psoriasis, ichthyosis, cancer, lupus, and the 
like. Some come into action once in a lifetime. Some are in 



54: ETIOLOGY. 

constant operation. Others only at stated periods, so that certain 
diseases are wont to appear at particular periods of life. 

Upon the nature of the cause depends the contagious or non- 
contagious quality of any disease. It is generally held that 
parasitic and the acute specific diseases are contagious. I shall 
describe a form of impetigo which is contagious. 

The special influence of age, hereditary transmission, occupation, 
and heat, will be dealt with in the opening of the chapter on 
general diagnosis. 

Sex has some influence as a cause of disease ; males suffer by 
preference from sycosis, pemphigus, psoriasis, bucnemia, eczema, 
and epithelioma; and females from acne, kelis, and lupus 
especially. 

It would be a very interesting matter to discuss at length the 
probable influences by which diseases are determined to different 
parts of the body. The facts in our possession at present do not 
however enable me to do more than indicate a few agencies that 
act in a definite manner in this respect. Diseases are determined 
to special parts. 

Amongst other things, by — 

1. The general or local nature of the cause. The whole skin 

is affected, of course, in acute specific diseases. Locally 
acting causes give rise to local diseases. 

2. By physiological changes, in which the occurrence of dis- 

ease is favoured by the non-performance (or hyperactivity) 
of some proper process in some organ. For instance, 
at puberty the hair formation and gland functions of 
the skin are called into activity, and any failure in the 
due formation of hair or the proper performance of the 
gland function may be a cause of disease : and this is the 
case in acne. 

3. The predilection of parasites for certain structures or parts, 

for instance, the hair in the case of fungi ; the interdigits 
and wrists on the part of acari : the pubes and the head, 
in reference to certain varieties of pediculi ; the parts 
kept warm and moist by flannel in the case of the fungus 
of chloasma. 

4. The special exposure of certain parts of the surface to 

external irritants — for instance, the face to the fire in 
cooks, or the face and the bared arms to the sun in out- 
door workers ; the bared legs in the case of the attacks 
of dracunculus disease ; the lower lip to pipe-irritation, 
evoking epithelioma ; the neck to the friction of the 
collar, inducing boils ; and various parts to scratching by 
the fingers, &c. 

5. Anatomical peculiarities ; such, for instance, as the free 

circulation in the tissues of the face liable to be influenced 
by all changes of temperature ; the large supply of glands 



ETIOLOGY. 55 

as well as their greater magnitude about the hairy parts 
of the face. 

6. A failure in the proper interdischarge of function between 

the skin and other organs, as when the kidney fails to act 
properly and throws greater work on the skin, which fails 
to perform the extra labour demanded of it, and so 
becomes disordered. 

7. The transmission of mischief by reflexion — for instance, 

from stomach to face, or uterus to the face — should be 
mentioned here. 

8. The contiguity to mucous surfaces, from whence inflam- 

matory mischief may travel to the skin. 

9. Auto-inoculation, as in contagious impetigo. 

10. Gravitation, as in the legs, by which certain tissues are 

disordered. 

11. The special affection of individual nerve trunks in connexion 

with the seat of eruption, as in herpes zoster. 

12. Hereditary tendency to morbid action in certain tissues. 

There can be little doubt that a disposition to the de- 
velopment of diseases in particular localities, not less 
than to the occurrence of diseases of particular qualities, 
is transmitted from parent to offspring. But then the 
local disease, or peculiarity of nutrition, so transmitted, 
must have existed in the parent or the direct ancestors 
for some time. It must have become, as it were, a habit 
of the individual. Ichthyosis is a case in point. This is 
certainly not a blood disease, or directly dependent upon 
a blood alteration. It is certainly hereditary. The same 
. may be said of psoriasis. 



CHAPTER Y. 

CLASSIFICATION. 

The object of classification is so to group skin diseases together 
that the student may be able to obtain at once a general view of 
cutaneous maladies in their rough outline, and also to compare 
diseases with each other with a view of tracing affinities between 
them. Much that has been said in the preceding chapter will help 
towards a clear conception of what is the best classification ; inas- 
much as it gave a general idea of the causes and the agencies 
operating disastrously on the skin. 

Skin diseases have been grouped in three chief ways : anato- 
mically, pathologically, and clinically. In regard to the two first, 
no complete system has been devised, and it is self-evident that 
the best mode must certainly be that which collects diseases to- 
gether, and arranges them side by side, in their mutual relation- 
ship, as exhibited in practice — in fact, clinically. 

I perfectly agree with Neumann that the purely histological 
standard-point cannot yet be adopted for classification, and that 
the etiology, clinical history, character, and course of skin diseases 
must be taken into consideration. But an approximation to an 
histological classification can be made, and Neumann has made it 
in his system, which is an improvement upon that of Ilebra. But I 
prefer my own arrangement for clinical purposes. 

The system of Willan and Bateman was as follows : — 

Order 1. — Pajndce, including strophulus, lichen, prurigo. 

Order 2. — Squamce, including lepra, pityriasis, psoriasis, 
ichthyosis. 

Order 3. — Exanthemata, including rubeola, roseola, scarlatina, 
purpura, urticaria, erythema. 

Order 4. — Bulla3, including erysipelas, pompholix, pemphigus. 

Order 5. — Pustulce, including impetigo, variola, porrigo, scabies, 
ecthyma. 

Order 6. — Vesicular, including varicella, rupia, vaccinia, miliaria, 
herpes. 

Order 7. — lubercula, including phyma, sycosis, verruca, lupus, 
elephantiasis, vitiligo, molluscum, acne, framboesia. 

Order 8. — Macula?, including ephelis, spilus, nsevus. 

I give the system here, since students are sometimes expected at 
examinations to be acquainted with its details. 

I believe that the following will be found for all practical pur- 
poses the best clinical plan of grouping skin diseases for the present. 
Skin diseases may be grouped as : — 



classification. 57 

1. Ekuptions of the Acute Specific Diseases (Zymotic). 

These I need not specify in detail. 

2. Local Inflammations, comprising — 

(a) erythematous inflammations, including e?ythema, inter- 

trigo, roseola, urticaria, pellagra, and certain medi- 
cinal rashes. 

(b) catarrhal inflammation, or eczema. 

(c) plastic, or papular inflammation, including lichen and 

prurigo. 

(d) bullous, including herpes, pemphigus, and hydroa. 

(e) suppurative, including those diseases that are essentially 

pustular — ex., ecthyma, impetigo contagiosa, and 
furuncular affections, inclusive of Delhi boil, Aleppo 
evil, and Biskra bouton. 
(/) squamous inflammations, including pityriasis rubra, 
and psoriasis. 

3. Diathetic disorders, including strumous, sphilitic, and lep- 

rous diseases of the skin. 

4. Hypertrophic and x\trophic diseases. Under this head are 

included on the one hand pityriasis, warts, corns, and 
ichthyosis, in which the epithelial layers are mainly affected, 
together with keloid, fibroma, scleroderma, &c, in which 
the connective tissue of the skin is involved — amongst 
hyperthrophies ; and on the other, atrophy, and senile decay 
amongst atrophies. 

5. New Formations, in which the neoplasm is the essential 

and only diseased condition present. This group includes 
cancer, lupus, and rodent ulcer. 

6. Hemorrhages — ex. , purpura. 

7. Neuroses, such as hyperesthesia, anesthesia, and pruritus. 

8. Pigmentary Alterations. 

9. Parasitic Diseases, including — 

(a) Animal, or dermatozoic, including scabies, or itch, and 

phthezriasis, or lousiness ; and affections associated 
with the chigoe, the dracunculus, the leptus, fleas, 
bugs, gnats, &c. 

(b) Vegetable, or dermatophyte including tinea favosa, 

tinea tonsurans, tinea herion, tinea circinata, which 
embraces Burmese, Chinese, and other ringworms, 
tinea decalvans, tinea sycosis, tinea versicolor, tinea 
tarsi, madura foot, and onychomycosis. 

10. Diseases of the Glands and Appendages, including — ■ 

(a) Diseases of sweat glands — ex., hyperidrosis, anidrosis, 

chromidro sis, miliaria, sudamina, lichen tropicus, &c. 

(b) Diseases of the sebaceous glands — ex., seborrhwa, astea- 

todes, acne, xanthelasma, molluscum contagiosum, &c. 

(c) Diseases of the hairs and their follicles. 

(d) " " nails. 



58 CLASSIFICATION. 

I really think that this is a very convenient method of grouping 
skin diseases after a clinical fashion. The student must have some 
plan of reducing the multifarious maladies of the skin from chaos 
to some order, and the above I have found to be both useful and 
acceptable. 

Now it will be observed I have not given in complete detail the 
various diseases included under the separate headings. I have 
purposely omitted the rarest forms of disease, and been content to 
indicate the various classes of skin diseases met with clinically, and 
to furnish examples which any one will recognise as illustrations 
of the different groups, even if he is only beginning the systematic 
study of skin diseases. Until the diseases falling under the several 
headings have been described in detail, it is impossible for the 
student to comprehend the reason of their being assigned such and 
such positions in the list. 



CHAPTEK VI. 

GENERAL DIAGNOSIS, PROGNOSIS, AND PRINCIPLES OF TREATMENT. 
I. GENERAL DIAGNOSIS. 

In making a diagnosis it is requisite to recollect the typical 
characters and course of eruptions; and that modifications of 
disease are brought about by diathesis, by chronicity, by remedies, 
by scratching, by abortive development, and by the intermingling 
or co-existence of two or more different diseases. The following 
are the chief points to be attended to in making a diagnosis : — 

THE MODE OF ONSET. 

The majority of cases of diseases of the skin are not preceded or 
even accompanied by severe constitutional disturbance; if there 
happen to be much fever and malaise, especially when the patient 
takes to bed from a sheer feeling of illness, and an eruption rapidly 
develops itself, something grave, probably one of the acute specific 
diseases, is present. This is all the more likely to be the case if 
the patient falls, as it were, suddenly ill. The main guide in these 
cases is the temperature : if the thermometer be raised in the 
axilla to 101 or 102 degrees F., and emphatically so if to a higher 
point than this, there can be very little doubt on the point. How- 
ever, amongst the occasional exceptions, acute lichen, erythema 
nodosum, secondary syphilis, acute eczema, pityriasis rubra, acute 
pemphigus, urticaria, herpes zoster, may be named, but these are 
not accompanied by high temperature. Secondary syphilis has 
been mistaken for the mottling of typhus and measles, acute lichen 
for measles, and herpes zoster for pleurisy, on account of the pain. 
It is merely necessary to be aware of these mistakes to avoid them. 
Occasionally in eczema there may be marked pyrexia, but not a 
markedly high temperature as far as my observation goes. When 
symmetrical, the disease is usually due to a blood-poison ; when 
unsymmetrical, to local causes or perhaps affections of the nervous 
trunks. 

COURSE AND GENERAL FEATURES. 

Perhaps one of the greatest errors committed in diagnosing 
cutaneous diseases is the dealing with them in a piecemeal manner. 
It is the universal expectation of the student to be able to diagnose 



60 COURSE AND GENERAL FEATURES. 

a disease of the skin from merely looking at it. Many a student, if 
asked with a patient before him, What is that disease ? will look — 
and, it may be, look closely — and then make his diagnosis and 
give the thing a name. Now in the case of no other class of 
disease would he do that. He would in the case of a pericarditis 
or a pleuritic effusion make the physical signs the guides to certain 
close questionings of the patient as to antecedent rheumatism, 
pain, subjective symptoms, duration of particular signs and symp- 
toms and the like, and he would base his diagnosis upon the 
phenomena of the disease as a whole. He ought to act similarly 
in reference to skin diseases. The course of skin affections prior 
to coming under observation, and the concomitants of the disease 
as it exists in the patient when he is actually seeking advice and 
treatment, should never be lost sight of in determining the nature 
of the disease. For example, nothing is more common than for 
the student to mistake chronic eczema in the later dry scaly stage 
for psoriasis. Now in the former there is a history of sero-puru- 
lent discharge, and none in the latter. The one has been inflam- 
matory, the other has not, and to take a later stage as though it 
represented a disease is a great blunder. I should diagnose an 
eczema from the character of its onset, its primary lesion — vesicu- 
lation giving place to discharge of a peculiar character — its pas- 
sage through the crusting and desquamatory stages, its accompani- 
ment by itching, its seat, the morbid changes in the skin, and the 
general pallor and badly nourished state of the individual, and the 
cause probably also. This line of behaviour should be made a 
rule. Diseases should be dealt with in their entireties, and not in 
a piecemeal manner, and mere accidental sequences — oedema, 
induration, Assuring, &c. — should not be considered as primary 
and essential features. 

One of the first cares, indeed, of the dermatologist should be to 
distinguish in diagnosis between primary and secondary pheno- 
mena. The one set are of course essential points of the disease, 
and the secondary results may, if care be not taken, be elevated 
to the rank of important items. I will take one instance. In the 
case of an erythema in connection with long-continued con- 
gestion, more or less thickening may occur ; if this be not clearly 
perceived to be an accidental occurrence, the diagnosis becomes 
difficult. Take the case of pityriasis rubra, a disease in which the 
whole skin becomes intensely hypersemic with free shedding of 
scales. If this be properly treated it will disappear, and leave not 
a trace. It may be unaccompanied throughout its course by any 
thickening of the papillary layer ; but if it continues a long while 
this layer may be thickened, and then there are present hyper- 
emia, papillary hypertrophy, and scaliness, as in psoriasis ; and 
the diagnosis between pityriasis rubra and psoriasis could not be 
made from the mere surface appearances and alterations only. 
But the two things clinically are wholly different. This shows the 



PERIODICITY OF THE DISEASE. 61 

importance of attending to the primary elementary lesion and 
the history and course of diseases. 

Again, in searching for the earliest stage of disease when that 
occurs in patches, it is necessary to go to the edge of the disease 
since it there presents its most recent characters. 

The typical course and characters of any disease may be masked 
by the co-existent development of a second disease, and here the 
interminglage of the features of the twain will be detected, as in 
urticaria and scabies or purpura : scabies and syphilis ; eczema 
and scabies : eczema and psoriasis, and the like. The capricious- 
ness as regards its appearance and disappearance of an eruption of 
an erythematous type, is suspicious of urticaria. Multiformity 
means that a disease is complicated, unless it be scabies or 
syphilis. 

TEMPERAMENT. 

The dermatologist is generally enabled to say at a glance 
whether a patient is of full habit and likely to have a loaded 
system — especially the case in women ; whether there be organic 
disease, or if there be a dyspeptic habit, or an ill-fed system, 
that signifies debility. If lymphatic, the patient is prone to 
eczema, impetigo, intertrigo, the pustular aspect of scabies and 
ringworm ; if gouty, the scaly diseases, chronic eczema, and 
lichen agrius ; if rheumatic, erythema nodosum ; if strumous, 
eczema, lupus ; if florid, psoriasis especially. There is also the 
cancerous cachexia, and in nervous subjects various hyperesthesias 
engrafted upon ordinary eruptions. Red-haired subjects are 
declared to be very liable to pityriasis of the scalp. 

THE DURATION OF THE DISEASE. 

Hereditary diseases are chiefly — leprosy, psoriasis, ichthyosis, 
lichen, eczema, syphilitic disease, and pigmentary anomalies. 

Congenital diseases are chiefly — syphilodermata, pemphigus, pig- 
mentary nsevus, and ichthyosis. 

Chronicity. — The more chronic a disease is the more does it tend 
to become a local disease ; and this is the case with hereditary 
affections (hence in these cases local treatment is the most 
important). 

PERIODICITY OF THE DISEASE. 

Some eruptions are more or less periodic in their occurrence, as 
in the case of pemphigus, but the dermatologist should remember 
that in districts where malarious disease is common, as in the 
West Indies, a disease not usually possessing periodic features 
may sometimes be so influenced that its eruption occurs in a 
" periodic " manner, or the febrile disturbance by which it 
is accompanied may show itself in "periodic" outbursts. I 
ha\e noticed this in regard to those who have returned from 



62 THE SEAT OF DISEASE. 

abroad. The physician must not forget to recognise the fact, that 
a periodic character may be impressed upon disease by malarious 
influence. The action of quinine is marvellously efficacious in 
these cases. 

THE RECURRENCE OF THE DISEASE. 

Psoriasis, eczema, and syphilitic diseases are essentially those 
which recur. 

OCCUPATION OF THE ATTACKED. 

Cooks are particularly liable to eczema and erythema, and 
bakers, grocers, and bricklayers to lichen agrius about the backs 
of the hands ; chimney-sweepers are liable to epithelioma of the 
scrotum; cotton- workers to urticaria; butchers and graziers to 
whitlow, boils, and malignant pustule and ecthyma; dragoons 
and shoemakers to eczema marginatum in the fork of the 
thighs ; young women who come from the country and have 
the full diet fare of the London servants and those who change 
their mode of life, so that it entails more exercise and better 
living, get an overloaded system that shows itself in erythema 
papulatum, erythema nodosum, or impetigo. 

AGE OF THE PATIENT. 

This is very important. During the first six weeks of life con- 
genital syphilis develops itself; intertrigo, eczema of the scalp, 
and seborrhcea capillitii also occur about the same time. Syphilitic 
pemphigus occurs, it is said, before the child is six months old, not 
afterwards; during the first few months and up to and through 
the period of dentition, strophulus and eczema are met with. I 
need only mention important facts. Cancer (epithelioma) is a 
disease of late life — it does not occur before thirty, generally about 
sixty; and rodent ulcer about the age of sixty and beyond. Lupus 
is a disease which commences in early and young life, and the 
same may be said of syphilis. The parasitic diseases occur in the 
young, rarely after twenty-one years of age. Herpes circinatus 
(or, as I call it, tinea circinata) is the form seen in adult life. In 
old people, phthiriasis, ecthyma cachecticum, pemphigus, and pru- 
ritus, with cancer and rodent ulcer, frequently occur. 

THE SEAT OF DISEASE. 

On the scalp the following occur : seborrhcea, parasitic diseases, 
kerion, eczema, impetigo, sebaceous cysts, alopecia, and psoriasis ; 
about the ears, eczema ; forehead, psoriasis, syphilitic acne, pig- 
mentary staining, leprosy, and herpes zoster ; near the eye, chromi- 
drosis, rodent ulcer, xanthelasma or vitiligoidea, and molluscum ; 
about the face generally, acne, impetigo contagiosa, erysipelas, lichen, 
syphilitic eruptions, erythema ; about the nose, lupus and acne 
rosacea; cheeks, lupus, malignant pustule, acne rosacea, rodent 



DIAGNOSTIC FEATURES OF ERUPTIONS. 63 

ulcer ; upper lip, impetigo sycosiforme, herpes labialis ; lower lip, 
epithelioma ; chin, sycosis ; whiskers, acne sycosiforme, and non- 
parasitic sycosis ; angle of mouth, congenital syphilis and eczema; 
chest, chloasma and keloid ; under the clavicles, sudamina ; aboiit 
ihe nipples, %n women, scabies ; on the side, shingles ; outer ^^pos- 
terior aspects of the trunk, prurigo and lichen, as distinguished from 
eczema occurring on the inner and front aspects ; about the elbows and 
the knees, psoriasis ; interdigits and about wrists, scabies ; back of 
hands, lichen and grocers' and bakers' itch ; palm of hands alone, 
syphilitic disease ; buttocks and feet of children, scabies ; upper line 
of penis, scabies ; scrotum, eczema, psoriasis, and epithelioma in 
chimney-sweepers ; front of leg, erythema nodosum, and in old 
people, eczema rubrum ; about the anus in children, congenital 
syphilis, and in adults, eczema ; travelling or developing over, 
and affecting generally the body, pemphigus f oliaceus and pityriasis 
rubra; In the bend of joints and armpits, eczema rubrum ; and 
limited to the hair follicles, lichen and pityriasis pilaris and lichen 
planus ; and to these and the sebaceous glands, lichen scrofulosus. 

DIAGNOSTIC FEATURES OF ERUPTIONS. 

Maculce (see pp. 27, 28). 

Erythemata. — These consist of hypersemia simply, and end in de- 
squamation. Mistakes generally occur with roseola, which is con- 
founded with erythema papulatum and rubeola; but it is never 
accompanied by distinct catarrh. The rash of roseola is rose- 
coloured at first, gradually getting duller, whilst, unlike measles, it 
is non-crescentic, but occurs in circular patches from half an inch to 
an inch in diameter ; not on the face : and the rash is often very par- 
tial in its distribution. In acute diseases erythema oftentimes occurs 
about the arms and limbs, as in cholera or rheumatism. Ordinary 
erythema is of a darker hue than roseola: it has a bluish tinge at 
its edge, and is not so well defined — i.e., is more diffuse. The 
erythema of erysipelas is accompanied by tension, shining, smart- 
ing, and swelling. E. scarlatiniforme presents all the characters, 
as regards the rash, of scarlatina, but lacks its general and throat 
symptoms and the peculiar appearance of the tongue. The rash is 
seen about the neck, the flexures of the joints, and the trunk ; it 
lasts five or six days, and is often more or less evanescent. The 
rosalia of authors — rubeola notha, or rubella — holds the same 
relation to rubeola that E. scarlatiniforme does to scarlet fever, that 
is to say, there is an absence of the general symptoms, the 
eruption however being similar, though more partial. 

Papidoe on the outer aspect of the limb mainly, with a thickened 
state of skin, constitute lichen; those with slightly dark apices 
(coagulated blood) occur on the arms and anterior aspect of the 
trunk, as a complication of scabies and of strophulus (prurigi- 
nosus) in children ; to a marked extent they are seen in phthiriasis, 



64: DIAGNOSTIC FEATURES OF ERUPTIONS. 

accompanied mostly by an atrophied state of skin and " broad " 
papules formed by an exaggeration of the little areas enclosed by 
the natural furrows of the skin ; intermingled with vesicles and 
pustules in scabies ; soft and red, and intermingled oftentimes with 
erythema in the strophulus of children ; flat and reddish, at first 
discrete, and subsequently collected together in little parcels, in 
lichen planus ; aggregated and confluent in lichen circumscriptus ; 
formed at the hair follicles, in lichen pilaris and planus, pityriasis 
pilaris, lichen scrofulosus, and the lichen of phthisis. The most 
common mistake, that of confounding lichen, and scabies, is at 
once avoided by observing the multiform aspect of the latter and 
the uniform character of the former. 

Vesicles and pustules. — The eruptions in which these occur are 
eminently characterized by the occurrence of discharge ; and dis- 
eases may, in reality, be roughly divided in this respect into two great 
classes, the dry and the moist : in the one class, where secretion or 
discharge occurs, crusts form; in the other, crusts are entirely 
absent. The character of the secretion affords most reliable informa- 
tion. If there be serosity, without crusts, the disease is intertrigo ; 
if thin, few, flimsy, light-coloured crusts form, and the discharge 
stiffen linen, the disease is eczema ; if the crusts be a little thicker 
and in little circular patches, herpes or tinea circinata is present. 
If the discharge be sero-pundent, forming yellow crusts, the 
disease is eczema impetiginodes ; or if there be light yellowish 
scabs that appear as if stuck on and flattened, impetigo con- 
tagiosa ; purulent masses, forming thick masses of a yellow 
colour, becoming more or less dark, occur in ecthyma, fu- 
runculus, purulent scabies, impetigo sycosiforme, impetigo 
scabida, and sycosis; whilst cockle-shaped crusts are very 
characteristic of rupia. Sanious pus is found in rupia and 
ecthyma cachecticum. Fatty crusts form in acne sebacea, 
seborrhcea, and sebaceous or false ichthyosis (legs). Hcemorrhagic 
discharge occurs in hsemidrosis, &c. Ulcerative diseases are 
easily recognised. 

It is necessary to distinguish scales from crusts: scales 
are altered epithelial cells. .Redness with scales, lasting on to 
chronicity, is seen in tinea circinata, erythema circinatum, and 
herpes iris. Scales, as a primary formation, occur in a partial 
manner in psoriasis; covering over the body generally in ichthyosis. 

Tubercula.- — There are four diseases somewhat alike, in which 
" tubercula " occur : the characters of the tubercula in these 
several diseases are as follows : — 

In Cancer (epithelioma) tubercules are solitary, flat, hard, and 
tender. Scabs are slight. When ulceration sets in the glands 
enlarge. There is much infiltration around the ulcer, which is 
papillated, dirty-greyish, ichorous, or semi-scabbed, with hard, 
everted, and undermined edges. Epithelial elements may be seen 
by the microscope. 



THE PROGNOSIS. 05 

Rodent ulcer begins as a small, pale, pretty soft tubercle, of very- 
slow growth. It is almost painless, and gives rise to an ulcer, 
without glandular enlargement. The ulcer has a clean surface, it 
is not papillary, it is without ichor, but it has hard, sinuous, non- 
everted, and non-undermined edges- 

Lupus has as its base an erythema, the skin looking seared ; then 
upon this arise dullish-red, softish, round, gelatinous-looking 
tubercles, forming patches of various extent. Thin adherent 
crusts form. There is no pain. The course is indolent. The 
edges of the patches are inflammatory, rounded, and raised, but 
not everted. There is always a tendency to repair, and cicatrices 
form, accompanied by distinct loss of substance. 

In Syphilis the tubercles commence as papules ; they become 
hard, large, and flattish, but not so flat as those of lupus ; they 
are dull-red at first, then coppery, and often in circles ; they 
pustulate or ulcerate, or increase by a serpiginous growth, 
and they are sometimes covered by thick dark scales. There 
is an ulcerating and a non-ulcerating form, the ulceration 
being often serpiginous and misnamed " lupus." Syphilitic 
tubercles often occur about the face. The ulceration is dirty, ashy 
grey, sloughy, and ichorous, the edges sharply cut and everted, 
surrounded by tubercles of a copper tint. 

With regard to parasitic diseases, no serious difficulty ought to 
arise if a microscope is at hand. Nevertheless, favus and impetigo 
are confounded with pustular eczema, and tinea tonsurans : not- 
withstanding that the cupped-crust favi of the former and the dry 
nibbled patches of the latter ought to prevent mistake. Chloasma, 
with its itching and desquamation, is very frequently indeed mis- 
taken for syphilitic maculae. Sycosis is often non-parasitic ; in 
this case, no damaged split-up hairs will be present, whilst the 
disease travels up into the whiskers. 

II. THE PROGNOSIS. 

Skin diseases are rarely fatal. When they occur as secondary 
manifestations implanted upon already existing disease, especially 
those of long-standing and in debilitated subjects, they are to be 
regarded according to their extent and nature as indications for 
grave anxiety. However, pemphigus neonatorum, ecthyma ca- 
checticum, rupia, pemphigus foliaceus, are most likely to be fol- 
lowed by fatal results. Malignant diseases, of course, have a fatal 
issue. The sudden retrocession of cutaneous eruption is generally" 
considered a most prolific cause of serious consequences ; there 
can be no question that the latter frequently follow the former, but 
the modus operandi of the supposed cause is uncertain. 

Hereditary tendencies, especially when exhibited in a congenital 
manner, render the cure exceedingly difficult ; in some cases, for 
example ichthyosis, impossible. The older the patient is before he 
5 



66 . THERAPEUTICS. 

exhibits hereditary peculiarities the more likely is he to get well. 
The presence of the syphilitic or scrofulous habit, the frequent re- 
currence of the same disease, complications, mal-hygiene, severe 
disorder of the mucous surfaces, such as ophthalmia, otitis, muco- 
enteritis, severe local degenerations of tissue (as in acne rosacea), 
the fact of a disease having become very chronic, symmetrical ar- 
rangement of the eruption, intemperate habits, dyspepsia, uterine 
disorders (such as leucorrhcea), dentition, old age, or very young 
age, all conduce to protract and render the cure difficult. 

As a general rule, a prognosis is required, not as regards fatality 
or danger, but the difficulty of cure, and particularly the likelihood 
of recurrence. Lepra, psoriasis, ichthyosis, erysipelas, eczema, 
urticaria, and lichen, are the most likely to recur. 

All parasitic diseases are curable, and this depends upon the 
facility with which the parasite can be attacked and destroyed. 
In cases of loss of hair, a cure is said to be impossible if the hair 
has been lost pretty suddenly ; and especially, if there happens no 
subsequent attempt at re-formation, the scalp at the same time 
being white, shining, tense, lowered in sensibility, and apparently 
with atrophied and indistinct follicles. In all cases of skin disease 
the earlier the patient comes under treatment the more likely is he 
to get rid of the cutaneous eruption; in other words, the most 
important point as regards speedy cure is early treatment, before 
the disease has had time to become localized. 

III. THERAPEUTICS. 

For practical purposes, as regards therapeutics, I think diseases 
of the skin may be conveniently grouped under three heads : — 

1. Those which are purely local. 

2. Those which, though mainly local in their origin, are yet in- 
fluenced or modified by different conditions of the general nutri- 
tion, or, if the expression be preferred, by constitutional conditions. 
These diseases, in fact, require mainly local remedies, but demand 
the use of such as are general as auxiliaries to cure. 

3. Those which arise primarily or directly from disturbance of 
the general nutrition or system. Here general are the most im- 
portant, local measures being employed as secondary aids to cure. 

Xow in the first category may be placed warts, the simpler ery- 
themata, and inflammations excited by irritants of various kinds 
— e.g., erythema, simple eczema, herpes, cancer, keloid, fibroma, 
naevus, atrophia cutis, scleroderma, ichthyosis, and certain parasitic 
diseases. 

In the second category may be placed the simpler forms of in- 
flammation in badly nourished or debilitated subjects, eczema in 
its severer forms ; lichen, impetigo, ecthyma in some of its forms, 
pemphigus, acne, and psoriasis probably. 

Under the third head fall the eruptions of the acute specific 



TTTEEAPEUTICS. 67 

diseases : urticaria ab ingestis ; medicinal rashes ; all diathetic 
diseases — e.g., strumous disease, syphilis, leprosy; cachexias of 
special kinds — e.g., lead poisoning, malarial poisoning, &c. ; chro- 
matogenous (pigmentary) diseases ; neurotic diseases — e.g.. pru- 
ritus, diseases connected with disorder of the sympathetic system. 6zc. 
Before entering into further detail, it will be as well to remark 
here, that in order that treatment should be properly conducted 
in any case of disease of the skin, the natural history and course 
of the disease presented for medication should be known and re- 
garded. The object of the physician should be to cut short the 
natural course of the disease by all means if he can without ill 
effect, but, if not, to aid in conducting it through its natural 
course, if that be towards resolution. If the disease be a simple 
erythema induced by cold or the like, non-interference, rest, or 
protection of the part, may be all that is required. What not to 
do is cprite as important as what to do in diseases of the skin, and 
both are best learnt in their individual appropriateness to particular 
cases, by a knowledge of the natural history of cutaneous diseases, 
a point sadly neglected. The means adapted to directly check 
the progress of disease are chiefly local. The diseases whose 
course may be cut short by these direct local means are — (1) par- 
ticularly, local diseases induced by causes acting from without 
upon the skin — e.g.. simple eczema and traumatic erythemata ; 
(2) certain maladies in which it is only necessary that the destruc- 
tion of new tissue may be accomplished — e.g., warts, lupus, naevi, 
cancer, rodent ulcer ; or (3) disease the cause of which is local 
and can be rendered inoperative by local means, as in parasitic- 
diseases. 

In the majority of cases of diseases of the skin, the cause is 
acting from within outwards, and there is less chance of rendering 
that cause inactive by the direct use of appropriate medicaments. 
It is only by altering the whole character of the nutrition that we 
can effect a cure. In some cases, as in urticaria ab ingestis. a 
sharply-acting emetic relieves the patient of his trouble at once — 
and cuts short his disease. Local measures, as the rule, are 
adopted not with the view of cutting short, but rather (a) in the 
first place of moderating changes in the skin — e.g., hyperseruia, pus- 
formation, squamation. and the like; then (b) protecting the diseased 
part ; and (c) subsequently of rousing the circulation and absor- 
bents to a healthy action. 

My own belief is, that the early stimulation of most skin diseases 
does an infinity of harm, and I think this erroneous use of remedies 
arises from the want of a correct knowledge of the natural course 
of skin eruptions. 

I will now proceed to some more particular remarks touching 
the three groups into which I have divided diseases of the skin. 



68 THERAPEUTICS. 

CLASS I. 

In the first place as regards diseases that may be considered 
local. They are (1) local inflammations excited by irritants in 
persons of good health. It is often only necessary to recognise 
the fact that the skin will soon recover from the effect of the irri- 
tant; to see that the irritation set np be not increased, and to 
protect the part awhile. Frequently too much is done in these 
cases of erythemata. Astringents are used too freely and too 
early, from the physician forgetting that the ordinary stimulant 
action of the external air, heat, cold, friction, and the like, upon the 
hypersensitive, because hypersemic, surface is vastly increased. 
The exclusion of the air by powders, and the protection of the part 
by a layer of cotton-wool, if very simple and apparently a do- 
nothing affair, is in reality the best treatment ; whilst it is beneficial 
in direct proportion to its speedy and complete adoption. The 
active hyperemia having subsided, the vessels may have lost tone, 
and it is then alone that astringents and stimulants are advisable. 
This is a principle of treatment of no little importance. Its 
reasonableness is obvious and experimentally vindicated in practice. 
(2) Local degenerative changes — e.g., cancer ; hypertrophous 
growths, as keloid. The object is to destroy by caustics, or to 
remove by the knife or the ligature ; of course, the removal should 
be complete, free, and speedy. It is scarcely necessary to dilate 
on these points, which emphatically apply to rodent ulcer and its 
congener epithelioma. An exception is found in the case of keloid, 
which seems almost certain to return in the cicatrix. Pendulous 
tumours call for the ligature, as in molluscum. Whether the knife 
or caustic should be used, or both conjointly, must be, of course, 
decided by the circumstances of particular instances ; but this 
depends mainly upon the extent of disease. If, as in rodent ulcer 
and nsevi, the growth be small, caustic will of course suffice, but it 
should be freely used, and so as to attack some slight portion of 
the healthy tissue to make sure that all the morbid tissue is de- 
stroyed. If the growth be extensive, the knife should remove it 
freely, but by all means should a layer of caustic be subsequently 
used to secure the death of any stray particles or masses of the 
foreign growth. But even in the cases of persons in good health, 
of whom we are speaking, I hold that if the growth, and especially 
the edges, be very hyperasmic, it is better to attempt by simple 
astringents and exclusion of air to allay the hypersemia before 
attempting to destroy the local disease ; because I hold that diseases 
have a tendency to return — and likewise oftentimes to spread in 
cases where removal unfortunately happens to be incomplete — in 
direct proportion to the degree of hyperemia of the boundary line 
between the healthy and diseased tissues. There is still a third 
class of local diseases that call for local treatment mainly— viz., 
parasitic diseases. The mode of using parasiticides in cases of 
animal parasitic disease is simple. It is easy to do too much even 



THERAPEUTICS. 69 

here, and to apply the remedies to the wrong place. Sulphur in 
scabies is frequently used too freely, and for too long a time, so 
that long after all acari are killed, the parasiticide is applied to 
increase the accompanying follicular irritation, and to set up 
urticaria, eczema, and the like. In phthiriasis the lice and their 
ova are in the clothes, which require to be baked ; not in the body, 
which only needs a good washing or two, and not parasiticide 
treatment, which only keeps the lice from attacking it, and does 
not destroy them. With regard to vegetable parasitic disease, 
much that is special must be done, and the difficulties of treatment 
are great oftentimes, but I shall refer to these matters with special 
minuteness under the head of tinea. 

CLASS II. 

I now come to speak of what I have termed the mixed class of 
cutaneous affections, the components of which are very numerous — 
i.e., those which are essentially local, but are influenced by the 
state of the system at large. These demand for their relief a 
judicious combination of general and local treatment. In many 
instances, a disease excited by a local cause — i.e., intertrigo, eczema 
simplex — occurs in a badly nourished subject ; and the mal- 
nutrition of, or mal-elimination in, the patient prevents the pro- 
gress towards cure, which should, if regard be had to the local 
mischief itself, speedily happen. There are one or two special 
points in the therapeutics of these cases. I may say generally 
that in the early stages of these diseases the proper treatment is 
that which we adopt for pyrexial diseases in other parts of the 
body, and it is subsequently such as is of a tonic nature, and 
finally that which is calculated to remove chronic inflammatory 
thickening or the like. But there is something more than this to 
be considered. It is not enough to adopt a treatment recognised 
as suited to a particular disease. There are a number of influences 
that modify disease in different subjects, and that require to be 
carefully attended to. These influences are of very common 
operation, and arise out of the peculiarities of the patient. The 
dermatologist must determine not only what is best for individual 
cases, but how far the specific or formulated treatment for particular 
diseases should be added to, or modified, to suit these diseases in 
particular individuals. In fact, the treatment of the cases of skin 
diseases now under notice should be a combination of the remedies 
suited specially to the particular disease present, with those suited 
to the concomitants of the individual case. The following are the 
modifying influences to which attention should be given. 

Firstly. — It is important to recognise the great influence which 
scratching possesses in exaggerating certain diseases. Nothing is 
of more consequence than the use of special remedies calculated 
successfully to allay the irritation which forces the patient to 
scratch ; and to protect and to soothe the parts when scratched. 



TO THEKAPEUTTCS. 

Secondly. — The influence of general debility is at work not only 
to retard recovery in, but to favour the development of many 
diseases to a more severe degree than would otherwise be the case. 
It is not a question of debility producing this or that malady, but 
modifying the same. The debility may express itself mainly in 
the form of anaemia, want of nerve power, &c. ; and special and 
appropriate remedies given with a view to meet these several states 
will lead to an improvement in the general health, and thus in- 
directly favour the cure of any diseased condition about the skin ; 
for it does not need any proof from me that the nearer a man 
approaches in his condition the standard of health, the sooner and 
more certainly will he throw oif any disease about him, be it in 
his outer or inner surface or parts. But in practice I do not 
forget that the specific should be linked with general treatment. 
Now the relief of the debility of persons afflicted with diseases of 
the skin is to be accomplished not only by the use of medicines, 
but by mental and bodily rest, change of air and scene, and the 
like. These matters are by no means sufficiently considered. 

Thirdly. — Every attention must be paid to dyspepsia as affecting 
the origin and course of skin diseases. It gives rise, of course, 
indirectly to debility, to torpid action of the liver, to the generation 
of acridities that float about in the blood, and circulate freely 
through the skin to disorder it ; and lastly, it increases cutaneous 
hyperemia by reflex action. Dyspepsia must- therefore be regarded 
as a powerful inteiisifier of all hyperaemic states. 

Fourthly. — The circulation of retained excreta is always a cause 
of intensification of hyperasmic conditions. The blood charged 
by excreta, in passing through an eczema or a psoriasis, will irritate 
it, if I may so say, and thus necessarily tend to give it an inflam- 
matory character, whilst the progress towards cure will be retarded. 
I believe this to be one of the most important of all points to be 
attended to in treating diseases of the skin, and the principle is 
of almost universal application. It is a matter of common sense 
(but matters of common sense are apt to be very much neglected) 
that a poisoned blood-current — poisoned — i.e., " charged," with 
bile or nitrogenous matters which necessarily disorders the tissue 
nutrition and vascular supply — will not permit the cure to be 
accomplished so easily as if the blood were uncharged with the 
same elements ; and the removal of the latter will help the cure 
of disease, and that oftentimes in a marvellous manner. ISTow, 
whence come the excreta in the blood ? From (a) defective assi- 
milation, as in dyspeptics, torpid liver action, and from excessive 
waste ; or (b) from defective excretion, by the skin, the kidneys, and 
the liver. The skin has to get rid of a certain amount of effete 
products ; and if the skin acts sluggishly or scarcely at all, this 
may impurify to some degree the blood-current. So, again, deficient 
kidney action tells its own tale. The non-excretion of bile pro- 
ducts in the usual way, and their passage into the blood-current 



THERAPEUTICS. 71 

to circulate within it, is another cause of skin mischief, as in some 
cases of erythema, urticaria, and probably purpura. The severest 
case of general eczema I ever saw was excited by the circulation 
of bile through the skin in connexion with a most marked attack 
of jaundice. Of course in such a case the influence of the retention 
of the non-eliminated products is easily appreciated, but in other 
cases readily overlooked. There are minor degrees of blood-im- 
purification by bile, urea, aud the like. It seems to me that the 
treatment of diseases of the skin is essentially the physician's 
work, and not the surgeon's, for the very reason of the connexion 
between skin maladies and functional and structural changes in 
internal organs. 

Fifthly. — Deficient renal action, particularly in reference to the 
quantity of fluid discharged, is another matter of prime moment 
in regard to skin diseases. I am convinced that we do not, when 
the skin is disordered, sufficiently make use of the kidneys to 
relieve the skin of its work. There are three conditions in con- 
nexion with diseases of the skin in which the kidneys should be 
freely stimulated to active excretion of fluid : — (1.) Where, in con- 
sequence of organic disease of the heart or other cause, and in 
connexion with a sluggish circulation, there is a distinct tendency 
to fluid accumulation in the tissues. (2.) In all cases of hypersemic 
skin disease, and in the early stages of inflammatory diseases, 
where the blood tends to accumulate in the skin in connexion with 
pyrexia. And (3.) In diseases of the legs, where there is the 
slightest tendency to local or general oedema. In inflammatory 
diseases of the legs diuretics greatly counteract the injurious 
effects of mere gravitation, and they tend to relieve the engorged 
tissues. Diuretics are useful under all these circumstances, and 
emphatically so where the quantity of urine is already deficient. 
But I hold that in diseases of the skin generally a deficiency of 
urine calls for free stimulation of the kidneys to relieve the dis- 
ordered skin of its work as much as possible. Of course where 
there is free circulation with the blood of retained excreta the 
necessity for free kidney action is increased tenfold. The liberal 
administration of diuretics in a case of eczema of the legs in a 
gouty subject will often act like magic when all other remedies 
fail. 

Sixthly. — Gout and rheumatism have their special influence upon 
skin diseases. I might have referred to these modifying influences 
under the last head, for it is the excess of uric acid in the one and 
the presence of lactic or an allied acid in the other case, and the 
circulation of blood charged with these products through the skin, 
that cause special mischief in skin diseases, and give an inflamma- 
tory or irritable aspect to them. The older practitioners, in attri- 
buting to gout and rheumatism the causation of diseases which we 
now deem independent of them, were even nearer the truth than 
are some modern observers who put excessive faith in the local 



72 THERAPEUTICS. 

origin of disease. If gout does not produce, it often modifies skin 
mischief, as above stated ; and, after all, our forefathers were only 
at fault in regard to the use of terms. It is not an uncommon 
thing to find this or that eczema or psoriasis or lichen called gouty 
eczema, gouty psoriasis, gouty lichen. Practitioners have found 
that by treating patients affected by these forms of disease as 
gouty or rheumatic, as the case may be, the maladies have often 
speedily vanished when other measures have failed. They have 
imagined that the gouty blood lias caused the disease. It would 
be more correct to say it modified, aggravated, the disease, and so 
prevented the cure from taking place. With this explanation there 
can be no difficulty in seeing that gouty and rheumatic dispositions 
exaggerate hypersemic conditions in skin diseases, and give an 
inflammatory aspect to them very frequently. The removal of 
gouty influences must aid the cure of skin diseases. 

Seventhly. — The tuberculous and the strumous diatheses also, it 
must be remembered, considerably modify certain skin diseases. 
The tendency in the phthisical and phthisically inclined, and in the 
strumous is to a particular perversion of cell-growth in certain of 
the tissues, and notably the nbro-cellular : I refer to the tendency 
to the production of pus. Now it will be readily understood that 
this must have much influence upon local tissue-change in skin 
diseases. Given the occurrence of a local inflammation in a non- 
strumous and a strumous subject, there will be differences in the 
two instances, accounted for by the operation of the pus-producing 
tendency in the one and not in the other. The tendency to the 
pus-production, which may not have shown itself in action 
before, will be likely to do so when nutrition is disturbed by local 
inflammation, disordered innervation, &c., as the case may be. 
The strumous tendency takes occasion by the perversion of local 
nutrition to give evidence of its presence and to complicate matters. 
Of this fact experience assures us. Take the case of an. eczema : 
if it occurs in a strumous subject, it is accompanied by free pus- 
production. Acne in a non-strumous and acne in a strumous 
subject are different. In the latter case, the fibro-cellular textures 
of the wall and about the gland are implicated and inflamed, often 
presenting the appearance of the livid -red and indolent tubercular 
swelling of a strumous tubercle, whilst the acne spots suppurate 
freely and leave behind scars, indicative of the tendency to ulce- 
ration, which is another feature of the strumous habit. This is a 
simple but it is an important point in therapeutics, and, because 
simple, often disregarded as of no moment. In psoriasis in 
strumous subjects, the tendency to the production of pus is seen, 
and in this statement I am confirmed in my original opinion by 
my friend Dr. R W. Taylor, of New York, an excellent observer 
and worker. Therefore, in regard to phthisical and strumous 
subjects, whilst one treats the local disease, be it eczema, erythema, 
lupus, acne, or psoriasis, it is of great use to neutralize, by the con- 



THERAPEUTICS. 73 

junction of anti-strumous remedies, the bias of the general nutri- 
tion towards free pus-production, which will of course express itself 
in proportion as the diathesis is marked and the local derangement 
of nutrition severe. 

Eighthly. — An old syphilitic taint is to be carefully detected and 
dealt with in reference to skin diseases. This should be recog- 
nised as a distinct and special cause of chronicity in certain non- 
syphilitic eruptions. The tendency of fully-developed syphilis in 
the human subject is to produce a new growth in the fibrous 
textures, or to give rise to a modification of the normal cell 
elements of these parts. The altered or new tissue we call 
" granulation tissue." Xow, when syphilis modifies ordinary skin 
eruptions, it docs so by impressing upon them more or less of the 
characteristic tissue change it ordinarily produces, and in doing so 
may antagonize to some extent diseased processes peculiar to the 
disease which it modifies. Eczema may illustrate what I mean. 
The characteristic of eczema is the occurrence of serous catarrh in 
the papillary layer of the skin as the primary condition ; but if 
eczema occur in a syphilized subject, and the syphilis be active, 
then the tendency of the syphilis towards the formation of the 
granulation tissue may show itself, and the " serous effusion '* may 
in part give place to the formation of new tissue — i.e., the two 
processes may be more or less intermingled, or rather, I should 
say, the result is a compromise. This is exactly what I should 
be led to expect from an examination of the naked-eye characters 
of eczema in a syphilitic subject. There is less discharge and 
more thickening than usual, and than I should be led to antici- 
pate. So in psoriasis there is more thickening, less scaliness, and 
less vascularity, because the syphilitic tissue invades and presses 
upon the vessels in the normal tissue. Hence the effect of 
syphilis on ordinary skin diseases is to render them less typical in 
regard to naked-eye characters and to their course, because the 
additional element of syphilis retards the cure, whilst there is the 
superaddition of the element of " thickening " or " deposit " 
(granulation tissue), which is not explained as a mere sequence of 
hyperemia or the like. 

Whenever I meet with a case of unaccountable chronicity I sus- 
pect that a syphilitic taint is in the background ; and, for my own 
part, I believe that syphilis is a modifier of disease in local inflam- 
mations to a greater extent than has yet been expressed in any 
writings. Syphilis does not give evidence of its presence in 
these skin affections until some strain is put upon the nutrition 
of the tissues, and then an explosion takes place. A strain is put 
upon the nutrition of the skin when a local inflammation occurs, 
the normal resistant power of the skin is lessened, and the syphilis, 
taking occasion by the weakness, shows itself in action as a 
modifier of the inflammatory process as above described. 

" Chronic inflammatory thickening " is a matter upon which a 



74 



THEKAPEUTICS. 



few words must be said. In some cases this condition is found to 
be developed out of proportion to the degree of antecedent 
hyperemia both as regards its severity and its duration. My own 
belief is that in such cases it is to be explained by the existence of 
the strumous diathesis in the individual concerned, which often at 
once accounts for the infiltration of the fibro- cellular tissue with a 
low type of lymph, or the formation in it of a new tissue of a less 
perfect kind. At other times an old syphilitic taint may best 
explain the occurrence of thickening. At all events a mercurial 
course sometimes does wonders, as all know. Of course long- 
continued hyperemia in a person free from the two diathetic ten- 
dencies named, will lead to "chronic inflammatory thickening.'* I 
am now particularly referring to cases in which thickening and indu- 
ration either rapidly show themselves ; or in such a manner as to 
strike us that it is clue to some special tendency in the textures to 
hypertrophy, rather than to the hypersemia itself, because this has 
been but slightly marked. 

Ninthly. — There is a class of phenomena connected with reflex 
action which it is of some moment to pay attention to in treating 
skin diseases. He who would deal with the matter scientifically 
must never concentrate his attention solely upon the mere local 
changes in these diseases, but must especially be on the alert to 
discover, in disturbance of the nervous system, the frequent reason 
of the intensification of hypersemic conditions in the skin. I have 
seen not infrecpiently a redness of the skin produced by mental 
excitement or sudden fright in "nervous subjects; " and there can 
be very few who have not known an eczema rubrum made imme- 
diately very much worse by the same influence. Depression and 
mental excitement play great parts in aggravating hyperasmic con- 
ditions of the skin. That uterine mischief occasionally intensifies 
acne rosacea, that dyspepsia frequently makes acne much worse, 
and the like, are facts belonging to the same category. 

Tenthly. — The hygienic surroundings of patients must always be 
carefully taken into account in the treatment of diseases of the 
skin, in reference especially to the class of cases particularly under 
consideration now. It is in this respect that the treatment of 
hospital and private patients of the better class differs so much. 
The confined living-rooms, the breathing of impure air, the de- 
fective diet, and the neglect of cleanliness, are influences that 
aggravate skin diseases in the poor as compared with the rich. It is 
cleanliness and feeding up, with fresh air, that the poor want, in 
many cases of disease which would be relieved by purgatives and 
alkalies and nervine tonics amongst the better classes. 

Now the several modifying influences referred to under the fore- 
going heads may be present in different combinations, and it is the 
full recognition of this fact that leads to success in the treatment of 
skill disease. 

I now turn to the general principles of local treatment. The 



THERAPEUTICS. 75 

diseases to which I am now referring are, it will be remembered, 
the hyperemias, the simple inflammations in the debilitated, 
eczema, ecthyma, psoriasis, acne, pemphigus, &c. I am the advo- 
cate for *a much more soothing system of treatment than that 
usually adopted for these diseases, of which hyperemia is so fre- 
quently a part. And this leads to the question, What should be 
the object of our local measures % It is threefold: (1) at the 
outset, to moderate diseased, especially inflammatory, action ; (2) 
to protect the diseased, and therefore weakened, parts ; and at 
length (3) to stimulate, with the view of rousing the dormant 
tissues into due activity, and causing the removal of morbid de- 
positions and formations. My own conviction is that, in the early 
stages of hyperemia skin diseases, much of our current treatment 
is mischievous by reason of its activity. A soothing plan of treat- 
ment is wanted in all cases of early cutaneous congestions. By 
soothing treatment I mean one which diminishes congestion and 
secures an exclusion of air — one which, in fact, puts the skin in a 
state of rest. Heroic measures, designed to cut short an early 
congestive stage of a skin disease, often render the course of that 
disease chronic and persistent. In the early stages before the 
deep vessels are involved, much can be done to check congestion 
by mild applications ; whilst active measures do harm. For 
instance, in acute general psoriasis I have often seen aggravation 
of the congestion follow the use of tarry applications ; while great 
relief has been produced by alkaline and bran baths, and subse- 
quent oiling of the surface. I am not by any means the advocate 
of an expectant plan of treatment. I advise potent remedies to 
be employed after the congestive stages have passed. The dangers 
of over-stimulating are not imaginative ; and they are plainly 
made apparent, in cases accompanied by active hyperemia, by 
much irritability, or by a tendency to degenerative change in the 
skin, in the spread of the disease, and its undue chronicity. 

Xow for the details of local treatment. 

First, as regards moderating inflammatory action. It will 
naturally occur to any one, first of all, to remove special causes of 
local irritation in the case of Iryperemic skin affections. There 
are two sources of mischief I may specially refer to ; they are (a) 
the wearing of flannel next the irritable skin, and (b) scratching. 
I think flannel should never come in contact with an irritable skin ; 
it is a great source of irritation. It may be worn outside a linen 
garment, and the patient will not, under such circumstances, catch 
cold. The disuse of flannel is important in nettlerash, pruritus, 
eczema, scabies, the erythemata, &c. Scratching does an infinity 
of mischief. The usual plan for preventing it is to use some 
sedative lotion. I think it of great importance to employ emollient 
and alkaline baths freely, to allay irritation in the early stages of 
local inflammatory cutaneous diseases, and to subsequently protect 
the parts by appropriate coverings and applications ; and by in- 



76 THERAPEUTICS. 

ternal remedies to remove all cause of pyrexial disturbance, or alter 
such blood impurifications as lead to an intensification of the hy- 
peremia of the parts through which the blood passes. The baths 
which are best adapted to moderate inflammatory or* irritative 
action in the skin are bicarbonate of soda, 2 to 4 ounces, size from 
4 to 6 or 8 lb., poppy, and bran. The patient may remain in 
for ten minutes or so, and the skin should not be rubbed dry, but 
patted with hot towels. It is a good plan to oil the skin subse- 
quently, or to powder it with oxide of zinc, or to apply a simple 
calamine lotion. But care must be taken to use such means in fit 
conjunction with general remedies. If bile products or ureal 
compounds are in abundance in the blood, free purgation, or 
diuretics employed with a liberal hand, must not be neglected. 
Pyrexia must be met with appropriate drugs and dieting. In like 
manner the pam and hyperemia of an eczema in a gouty subject 
may be greatly moderated by an alkaline bath, but a good dose of 
colchicum in addition will bring the greatest relief. The exclusion 
of air from inflamed and hypersemic irritable parts is a matter of 
great consequence, and the more so if the irritable part is denuded 
of cuticle. The air is very stimulating to such parts ; absorbent 
powders and neutral unguents are here called for. Then it is 
also very desirable to prevent evaporation taking place from 
scratched surfaces, or surfaces denuded of their natural protecting 
layer of healthy cuticle, for thereby they become harsh, hard, and 
tend to crack. I know nothing so good for the purpose as the old 
" Kirkland's neutral cerate." 

I do not know that I can find a better place to make one refe- 
rence to the use of water-dressing to indurated and irritable parts, 
made all the more troublesome by scratching. There can be no 
doubt that the use of a water pad, which permits the diseased 
surface to absorb moisture and so become more or less soft and 
supple, does give great relief ; but this is oftentimes succeeded by 
the recurrence of itching, pain, and it may be, increased cracking 
and stiffness or tension. The explanation is not difficult to give 
in regard to some cases at least. The part has become denuded 
of its cuticular covering, and, whilst it absorbs moisture freely, 
it also parts with its moisture equally freely unless prevented. 
Whenever I use water-dressing to an excoriated part, I invariably 
direct that a layer of greasy matter shall be applied, and kept 
applied, on the removal of the compress. In this way the ab- 
sorbed moisture is retained, and the parts keep more or less 
soft. 

But I am touching upon the second point — viz., the protection 
of hypersemic and irritable parts ; and, indeed, to protect is, under 
such circumstances, to moderate diseased action. In order to pro- 
tect it is necessary to prevent scratching and also the access of 
the external air to the part : to secure rest, as it were, to the 
diseased parts 3 and to negative the operation of special external 



THERAPEUTICS. 77 

irritants. In addition to the use of absorbent powders arid neutral 
unguents, one may employ cotton-wool, bandages, and strappings, 
which I need not now discuss at any length. The use of ban- 
daging and strapping is particularly to be commended where the 
effects of gravitation are noticeable — in the legs, for example. 
The bandage prevents undue distension of the vessels and the 
escape of serosity into the textures, thereby giving the parts a 
better chance of recovering their tonicity. This simple matter 
is much neglected in regard to cutaneous diseases. Not only in 
the leg, however, but in other parts bandaging and strapping act 
similarly, where the tendency to engorgement of the tissues and 
vessels is shown. 

The third object of local treatment in *he diseases with which 
we are dealing is stimulation. One of the chief things the derma- 
tologist should set himself to determine is the exact time at which 
his soothing kind of treatment should cease and his stimulating 
remedies be employed. It is at the moment that the irritability 
of the blood-vessels and the nerves is subsiding that the use of 
powerful astringents and stimulants is so efficacious, and that it is 
possible to do the most towards a speedy cure of disease. What 
happens in the inflammatory eczema, the acne, or the psoriasis ? 
After a while, the vessels lose their tonicity and become dilated, 
favouring the "effusion of inflammatory products," giving rise 
to oedema, "chronic inflammatory thickening," &c. Now, it is 
at the moment that the parts are becoming less inflamed and 
irritable that astringents, lead, zinc, nitrate of silver, mild mer- 
curial preparations, and the like, are of use to restore to the vessels 
their tone. And if at the same time the general remedies assist 
nature by removing impurities from the blood, by restoring the 
balance between absorption and excretion especially of the watery 
matter of the system, and giving general tone to the body, the 
patient will probably get rapidly well. The application of sulphur 
at the indicated nick of time speedily cures an acne that had been 
irritated before by the same remedy. The same may be said of 
the use of nitrate of silver to an eczematous patch. The use of 
tar to a psoriasis which is markedly hypenemic at a very early 
stage will often spread the disease, or bring out fresh places. If 
matters still do not mend, but the disease holds on, one needs to 
stimulate, or, as we say, "rouse the torpid tissues to activity," 
but as I should put it, to quicken the activity of the absorbents 
in order that effused and formed products may be removed. 
It is really not so much in chronic inflammatory skin diseases 
that we need fresh remedies, as to use those we have, reasonably, 
as regards time and circumstances. This is emphatically so as 
regards eczema and general psoriasis. But what are the indica- 
tions that local soothing remedies are still needed in a disease, 
and the time has not come for stimulants ? I think the main ones 
are as follows : — The tendency of the hypersemia or the disease to 



78 THEKAPEUTICS. 

spread; the development of new spots of disease — showing the 
disposition to the implication of healthy parts — which would be 
favoured in its development by anything which irritated such parts ; 
the presence of much pain or heat in the parts; but more especially 
marked hyperemia. But I lay most stress on the two former 
features. I like to let hypersemic conditions in skin disease 
" quiesce," as it were, before I leave off my soothing treatment. 
But a disease having " quiesced," its hyper?emic condition having 
diminished, and the disease showing no tendency to spread or to 
spring up in new places — e.g., in acne, eczema, psoriasis, and pem- 
phigus — then stimulation can be appropriately adopted. And for 
what reason are stimulants used ? First, to restore the tonicity 
of vessels ; and one must not forget here that artificial pressure 
by bandages, &c, is a great assistance where gravitation comes 
into play to distend the vessels, as about the legs. Secondly, to 
alter the character of a discharging surface. Such is the action of 
a weak mercurial ointment in a case of chronic eczema. Thirdly, 
to check the formation of scales, as in the use, against psoriasis, 
of tarry preparations ; and fourthly, to cause the absorption of 
inflammatory or heterologous formations ; the iodides, mercurials, 
the soap treatment, blistering, and the like are specially referred 
to under this last head. But in regard to the use of stimulants 
and revulsives, I hold equally, as concerns their application, that 
their efficacy will depend greatly upon the judicious conjunction 
of internal remedies. I mean that, supposing that the blood of a 
patient in whom these external means are used is charged with uric 
acid, he will have a much smaller chance of gaining benefit from 
the application of revulsives than one who has a pure blood- supply 
passing through the diseased part. In the former the blood- 
state may take occasion, by the unbalancing of the nutrition 
induced by the use of the local remedies, to increase the hyper- 
emia, or to set agoing an inflammatory action again. The suc- 
cess of stimulant applications, in fact, will be in direct proportion 
to the degree in which the individual's condition approximates 
that of health. One very potent method of stimulating not only 
the skin but the system generally, and emunctory organs in par- 
ticular, is the use of sulphur or sulphuret of potassium baths. 
They should not be employed in the acute stages, but in the chronic 
forms of psoriasis, eczema, lichen, and acne. Where there is not 
much irritation or hypergemia, and where the latter does not seem 
to be readily increased, they are most useful. 

CLASS III. 

It is scarcely necessary to enter into detail as regards the com 
ponents of this class, including the strumous, the leprous, the 
syphilitic, and neurotic diseases. The general treatment is all- 
important, but it has nothing special about it. It is specific in so 
far as cod liver oil is our sheet anchor in the strumous ; iodide of 



THERAPEUTICS. 79 

potassium and mercury in the syphilitic ; arsenic, iron, strychnine, 
quinine, and the like in the neurotic cases ; but it may be shortly 
described as consisting in the use of general tonics. Locally, little 
is needed to be done saving getting rid of exuberant Granulations 
in strumous cases by astringents, and using absorbents, such as weak 
mercurials, to syphilitic and leprous growths. I have fully dealt 
with these several matters in detail under the head of particular 
remedies. 

Summary. — From the foregoing observations I hope it will be 
evident that the treatment of skin diseases consists in something 
more than the prescription of arsenic. The invariable answer I 
obtain to the question, "Why do you give arsenic?" is this: 
" "Well, you know one does give it !" or " What else can we give ?" 
I have attempted however to show that it is impossible to formulate 
a particular treatment suitable for all cases of any one disease — to 
say this or that man has this or that disease, and therefore must 
have this or that treatment. Most cases require a combination of 
medicaments, suited not only to the disease itself, whatever that 
may be, but also to varying individual peculiarities in the patient, 
and concomitant circumstances. I think it needs the knowledge 
and tact of the physician to make such a combination a happy one. 
Farther, I have especially dwelt upon the need of a more soothing 
and a less stimulating plan of treatment in the congestive stages or 
phases of all cutaneous disorders. 



CHAPTEE VII. 

THE ERUPTIONS OF ACUTE SPECIFIC DISEASES (ZYMOTIC,— WHICH 
ARE OF CONTAGIOUS NATURE, OF DEFINITE COURSE AND DURA- 
TION, ACCOMPANIED BY FEVER, THE RESULT OF POISONING; OF 
THE BLOOD BY SPECIAL VIRUSES— ONE OF THE EFFECTS OF 
THIS POISONING BEING THE DEVELOPMENT OF CERTAIN CHARAC- 
TERISTIC ERUPTIONS ON THE SKIN. 

The eruptions which call for notice under this head need not be 
discussed at any length. I think it necessary to give a short sum- 
mary only of the eruptions themselves, for diagnostic purposes. 

VARIOLA, OR SMALL-POX. 

The eruption in the skin is characterized by the appearance 
of bright, red, hard acuminated points, the size of hemp-seeds, 
distinct from each other at first, and which, passing through the 
stages of vesicular and pustular inflammation, arrive at their ma- 
turity on the eighth day of eruption. The individual pustules then 
scab, their contents drying into brown masses, which become 
detached in from twelve to twenty days, and leave behind in their 
place permanent cicatrices, or u pits." Small-pox is often pre- 
ceded, as regards its local state, by more or less erythema, which 
subsides on the appearance of the vari. This has been termed 
erythema variolosa. Small-pox is said to be discrete, when the 
pustules are scattered over the surface ; coherent, when the eruption 
is plentiful, and the vari are " closely packed side by side but still 
distinct ;" confluent, when they run together ; modified, when the 
disease succeeds to a prior attack or occurs after inoculation. 
The disease is also primary or secondary, in relation to the number 
of attacks in a given individual. Variola sine variolis is the name 
given to small-pox when the pyrexia proper to it occurs, but when 
at the same time this febrile state is unattended by eruption. The 
mucous surfaces are affected in like manner to the skin. Small- 
pox is, by universal consent, divided into five stages,— firstly, that 
of incubation, which is reckoned by the length of time which elapses 
between exposure to the poison of the disease and the develop- 
ment of the first effects (it varies in duration from 5 to 20 days — 
Dr. Marston, of the Small-pox Hospital, says its average is 12) ; 
secondly, the stage of invasion (2 days) ; thirdly, that of eruption ; 
fourthly, that of suppuration ; and fifthly, desiccation. 



OR SMALL-POX. 81 

The " Period of Eruption." — Eruption makes its appearance on 
the third day after the first occurrence of constitutional dis- 
turbance, and travels over the entire body within a day, when the 
febrile condition is greatly relieved. The spots appear first of all 
on the face, about the forehead, and thence they extend to the 
trunk and limbs. These spots are, in the very outset, small 
papules, red, hard, and pointed, and their more or less closely 
packed or scattered condition affords a good guide as to whether 
the disease will be confluent or not ; if the skin be very red and 
erythematous, probably the case will assume the confluent form. 
On the second day of eruption— fourth of disease — the papules 
formed from elevation of the epidermis by an increase of the cells of 
the Mal/pighian layer and distension of the vessels in the true skin, 
but particularly the papillary layer, are transformed into vesicles. 
If these vesicles be punctured, nothing escapes from the puncture. 
Now at this stage there is a network of fibres in the rete formed by 
stretched and elongated cells of that layer, the meshes being filled 
with pus cells, the papillae being flattened down. On the third day 
of eruption — fifth of disease — umbilication commences as a central 
depression, which becomes more marked every day,_£>«W passu with 
suppuration, which now commences ; the pustules are " whitish and 
surrounded by an inflamed areola;" the fourth day of eruption (sixth 
of disease). If the contents of the pustule are now turned out, a little 
"disc" of dirty plastic matter, presenting an umbilicated shape, and 
attached to the cutis beneath, will be noticed. At this stage pus 
cells infiltrate the corium more deeply, but the main collection is 
encapsuled as it were by two la} T ers of the rete cells, which are flat- 
tened out more or less above and below, the intervening cells being 
stretched out into fibres, forming a network as above described. In 
the confluent form these various changes are not distinctly traced. 
It is not at all unusual to observe the confluent in one, the discrete 
form in another part of the same subject. The onset of maturation 
is observed about the end of the fifth or beginning of the sixth day 
of eruption, or the eighth of disease. The contents of the umbili- 
cated vesicles soften down into pus, the umbilication diminishing with 
enlargement of the base of the pustule, and a yellow colour replacing 
the white. Maturation, as it is called, is " complete on the eighth 
day of eruption," or the tenth of disease ; between the eighth and 
eleventh day, or the tenth or thirteenth of disease, secondary fever 
sets in, when the stage of desiccation is reached. This is the period 
of recovery or resolution, when the local and general symptoms 
subside, the scabbing dries, and the discharge ceases. The crusts 
fall off in the next three or four days (fifteenth day of disease), ex- 
posing raw, red surfaces, which desquamate, and by-and-by leave 
behind red-looking marks, which gradually fade and assume the 
well-known aspect of small-pox marks. 

When small-pox is produced by inoculation there are some dif- 
ferences. On the third day the puncture is inflamed, it is itchy, and 
6 



S2 



VARIOLA, OR SMALL- POX. 



surrounded by a little blush of redness, whilst the spot is slightly 
indurated ; on the fourth or fifth day the central point acuminates, 
and a little coming vesicle is seen ; on the sixth day there is an 
early state of pustule, and it is umbilicated ; on the seventh day a 
perfect pustule is formed with an inflamed areola ; on the ninth 
or tenth day, maturation takes place, and the umbilication of the 
pustules goes ; from the twelfth to the fifteenth day, desiccation takes 
place, and from the twentieth to twenty-fifth day the scab falls off. 
The disease is rarely confluent. 

In dealing with vesicles and pustules under the head of elementary 




Vertical section through half of a pustule in process of retrogression (250 diam.), 
(Auspitz). a. Old epidermis, b. Rete Malpighii covering the meshwork. c. Swollen 
lateral cells of the mesh work. d. Mesh work with enclosed pus cells, e. Newly formed 
epidermis. /. Vessels surrounded by cells, g. Part of a sebaceous gland, h. Corium. 

lesions (chapter iii.), I gave a general sketch of the changes that 
take place in the tissues in small-pox, and the accompanying repre- 
sentation of a small-pox pustule, after Auspitz, taken in connexion 
with the sketch and the remarks above made, will enable the 
reader to form a good idea of the morbid anatomy, not only of 
variola, but also of parenchymatous inflammation in general. 



MODIFIED VARIOLA. 83 

DISFIGUREMENTS, ETC., AFTER SMALL-POX. 

The advice of the dermatologist is not infrequently sought for 
the removal of certain disfiguring consequences of small-pox about 
the body. 

In the first place redness of the face has to be dealt with thera- 
peutically. This may be rendered much less visible by the use of 
some mild astringent, but the greatest care must be taken to 
avoid every application which could in any degree increase by 
stimulation the hyperemia. A calamine lotion is as good an 
application as any (see Formulas, No. 117). It should be used 
after bathing with hot water, being dabbed in and allowed to dry. 
Scarring cannot in the nature of things be prevented, though by 
letting out the pus from the pustules, or aiding in the solidification 
of the pus, the degree of scarring may be much lessened. If the 
scars become the seat of hypertrophous growth of cicatricial 
tissue — a species of keloid developing — the knife must not be used 
to these cases, but the frequent application of contractile collodion 
had recourse to. It should be applied twice a day for some time. 
The formation of warty projections in the face calls for notice. 
These are hypertrophic growths of the fibrous texture, resulting 
from the inflammation of the tissues, and can be nipped off with 
the scissors, or destroyed by acid — such as the acid nitrate of 
mercury ; but the use of such a remedy requires care. 

Acne spots may also develop about the nose, for which the 
ordinary treatment for acne should be adopted. 

In some cases enlargement of the sebaceous glands, by the 
retention of secretion in them, owing to the mechanical obliteration 
of the follicular passage, occurs, and then what is termed variola 
verrucosa is present. It may be destroyed by caustic. 

Eczema following small-pox should be treated in the usual 
manner. 

MODIFIED VARIOLA. 

The effect of vaccination is to lessen the severity of variola, and 
the latter occurring in vaccinated subjects is called modified 
small -pox. 

There are differences of opinion as to whether there is any rela- 
tion between it and varicella. The distinction of varicella (vesi- 
cular), modified smalhpox (varioloid, as it has been termed), and 
variola is well marked in the extreme degrees of either disease, but 
they shade the one into the other by insensible stages. At times 
cases are met with which may be called either variola or varioloid 
— indeed it is not uncommon to observe the vesicular in conjunc- 
tion with the umbilicated form ; at other times an eruption is 
simply papular and scarcely reaches the vesicular stage, yet is 
traceable to the action of the small-pox poison. Varicella has 
been regarded as small-pox modified by vaccination, but there is 
good reason to look upon it as a distinct disease. 



84 INOCULATED VACCINIA, OR VACCINATION. 

In modified variola, as compared with true variola, the secondary 
fever is absent : the only stages present are those of primary fever 
and eruption. As a rule the pyrexial symptoms partake of the 
character of those of variola, but they are of less severity. The 
eruption may be papular ; in this case it behaves in the same way 
as that of variola at the ontset, only it is abortive at the papular 
stage, and in a few days the papulae subside ; there are a few vesi- 
cular and pustular spots generally about the face. At other times 
the vesicular stage is reached, and lasts five or six days, and, as in 
the papular variety, there are a few pustular spots on the face. 
In more marked instances, the modified variola is pustular, and 
the pustules may be globular (the varicella globularis of Willan, 
and swine- pox of old authors) or umbilicated, or the characters of 
these two varieties may be intermingled with those of conical 
vesicles. In other words, modified small-pox may abort in any of 
the stages which are passed through by ordinary variola. 

VARICELLA. 

This is a disease of children. After pyrexia lasting a few hours, 
or not more than a day, the eruption of varicella appears, often 
on the back first of all, as distinct red papulae, which become 
vesicular in a few hours : the eruption is successive during three 
or four days. The same kind of changes occur in the eruption as 
in variola, but the disease is more superficial, and the vesicle is 
unilocular, and it is not generally umbilicated ; the contents are 
serous rather than puriform. On the first day the vesicles are 
transparent ; opalescent on the second and third ; on the fourth 
they shrink and desiccate ; and on the sixth the scabs fall off. 
Sometimes, however, the contents of the vesicles become puriform. 
The general pyrexia is slight. 

Varicella is diagnosed from the vesicular variety of modified 
small-pox, by the less severity in the antecedent pyrexia, the 
absence of the " shotty " feel of the eruption in its papular 
stage, the rapid formation of the vesicles, the absence of much 
inflammatory local hardness, the successive crops of the erup- 
tion, its commencement on parts other than the face, the absence 
of pitting, the superficial character and the shortness of the 
course of the disease, and the absence of secondary fever. The 
disease is over in a week or so. 

INOCULATED VACCINIA, OR VACCINATION. 

Course. — On the third day after vaccination there is seen a 
slightly red point if a puncture has been made, and a red line if 
a scratch has been made, at the seat of operation. The part is also 
slightly elevated. On the fourth day these signs are found to have 
augmented, and the papular stage has been reached, and this co- 
incidently with the development of distinct local inflammation, ac- 



INOCULATED VACCINIA, OR VACCINATION. 85 

companied by pruritus and irritation. The edges of the wound are 
everted, thickened, inflamed, and hot, with a commencing blush of 
redness around them. The disease may now abort, but usually 
on the fifth day the epidermis is raised so as to form a vesicle, 
which is well formed on the sixth day, when it is of a whitish 
colour, of circular form, and exhibits commencing umbilication in 
the centre. The vesico-pustule attains its full size on the eighth 
day (fifth of eruption). It is then distended but flattened at the 
top, whitish, and surrounded by a red areola, and more or less in- 
duration ; the parts around now become irritated, tense, brawny ; 
the glands enlarge, whilst the blush of inflammation extends 
oftentimes to the shoulder, or down the arm itself. On the ninth 
day the umbilication is lost, and the pock is getting pustular. If 
the vesicle is punctured, around the edge especially, a transparent 
fluid exudes. On the eleventh day, the blush of inflammation 
begins to subside ; the contents are markedly pustular, and the 
stage of desiccation commences. Up to this period the vaccine 
vesicle is chambered, so to speak, into separate cells ; these now 
open the one into the other, and form one large pustule ; the de- 
siccation advances from the centre in the next few days (12th, 
18th, 11th) towards the circumference ; the crust also dries, so 
that a dark, hard, dry, shrivelled scab remains; the redness has 
in great measure gone, but there is a lividity about the vesicle ; 
the crusts separate from the seventeenth to the twenty-fifth day, 
leaving behind cicatrices, at first of darkish colour, but which soon 
fade in colour, but are permanent. Mr. Wilsen recapitulates thus 
in regard to the stages of the disease : — First two or three davs, 
incubation; 4th, papular ; 5th to 8th, vesicular (umbilication); 
8th day, areola; 9th to 11th, pustular \ umbilication lost, areola 
enlarged ; 15th to 17th, period of separation. 

Eruptions following Vacchmtion. — Amongst other things erysip- 
elas may be noticed. The only point calling for comment in regard 
to it is the desirability of evacuating the contents of the pustules as 
soon as possible, and freely incising the tissues around the seat of 
mischief, if there be much tension, brawniness, or threatening sup- 
puration. Sometimes an eruption makes its appearance on dif- 
ferent parts of the body immediately after or coincidently with 
that of vaccination, and partakes of the characters of vaccinia. 
This has been termed vaccinola and " bastard vaccinia." Neumann 
states that the contents of the vesicles, when introduced beneath 
the skin of a healthy person, "produce varicella or varioloid." 1 
Of this particular fact I have had no personal experience, though 
I have observed cases of vaccinola, which, I think, implies that 
the activity of the virus does not cease with the period of de- 
siccation in vaccinia. The treatment of this latter affection is 
that of vaccinia. Eczema in different forms may follow directly 
upon vaccination, and then the subject attacked by it has been 
generally either badly nourished, or bad hygiened, or is strumous. 



86 TYPHUS RASH. 

Where the eczema is slight, there is no difficulty in curing the 
disease by the use of such simples as zinc ointment, and a few mild 
aperient doses followed up by a little tonic. But in some cases 
eczema more or less general follows vaccination, and then I regard 
the patient as one in whom a constitutional predisposition to the 
disease has already existed, the disease being excited merely by 
the vaccination, and its attendant disturbance of nutrition. In 
these cases the eczema may begin about the seat of the actual 
vaccinia, and spread away from thence over the body, or it may 
crop up in different parts of the surface. In either case the 
symptoms are those precisely of a chronic eczema, with a thick- 
ened harsh skin, which is oftentimes very irritable. The treat- 
ment is that of chronic infantile eczema. Contagious impetigo 
and furunculi occasionally follow vaccination ; and lastly, vaccinal 
syphilis. Now I do not think it at all necessary to enter into a 
lengthy disquisition upon vaccinal syphilis. Unquestionably it 
does occur, for I have seen it myself. But it never occurs where 
unadulterated lymph is used, and only where the lymph is impuri- 
fied by admixture of actual syphilitic pus or blood. When " vac- 
cination is performed on a healthy person with lymph from a 
vaccinated syphilitic patient, and blood is mingled with the matter, 
then, instead of a vaccine pustule being developed, there is an 
infiltration which shows clearly the character of the ulcus indu- 
ratum " (Neumann). The guide then to syphilitic mischief is the 
fact that the vaccinia does not run a typical course, and that in- 
duration or unhealthy ulceration occurs at the time that desicca- 
tion and healing should rapidly take place ; the ulceration and 
induration taking on it may be a serpiginous character to be 
followed subsequently by " secondary eruption." But there is 
another very important point to notice : vaccination may be fol- 
lowed by syphilitic ulceration itself, due not to the introduction of 
syphilitic matter through the medium of the lymph, but due to 
the operation of the syphilitic taint already possessed by the 
child. Of this I am confident. The treatment of these cases is 
that for syphilitic affections of course. 

TYPHUS RASH. 

This consists of two component parts : — 

1. A subcutaneous mottling, of a more or less livid hue, and dif- 
fused generally over the body. 

2. Petechise, small, about the size of pins' heads, scattered all 
over the body, and showing out from the mottling ; at first these 
are slightly raised, and their colour increases gradually in inten- 
sity ; they do not fade by pressure, except slightly in the very 
early stages. The eruption of typhus is not prolonged by suc- 
cessive crops. It makes its appearance between the fifth and 
eighth day of disease, and disappears a few days before con- 
valescence. I have known it to be mistaken for syphilitic rash. 



SCARLATINA. 87 

TYPHOID RASH. 

Is characterized by the appearance between the eighth and twelfth 
day of disease of rose-coloured, elevated, circular, softish spots, 
about a line or so in diameter, on the abdomen, back of hand, arms, 
chest, and back (if kept warm). These rose-coloured spots dis- 
appear by pressure, and they appear in successive crops, each spot 
lasting three or four days, and then gradually fading. There may 
be from half a dozen to a score of these spots present at one and 
the same time. Sudamina often co-exist with them. 

RUBEOLA (MEASLES), OR MORBILLI. 

About the fourth day after the patient is taken ill with 
catarrhal symptoms the eruption appears, first on the face, 
especially the forehead, then on the chest and limbs ; it reaches 
its height in the former situation in about two days, when it 
begins to fade. The changes are a little later on the other parts 
of the body. The eruption lasts altogether about four or five 
days, and leaves behind sometimes a little, at other times a 
marked amount of desquamation, perhaps a good deal of mottling 
or red staining, especially if the circulation has been inactive. 
The rash has peculiar features ; it is of a dullish red colour, and 
forms little crescentic or semilunar patches of variable size, affected 
by the pressure of the finger, and separated by natural skin.' The 
colour also may be livid if the blood state is bad. The crescentic 
form is supposed to be due to the peculiarity in the distribution of 
the cutaneous filaments of the nerves. The whole mucous sur- 
faces are also affected, as may be seen in the palate, &c. After 
death no trace of the rash is to be detected about the body. 

Diagnosis. — The characteristic points are the crescentic form, 
with intervals of normal skin ; the dull colour of eruption, which 
appears on the third or fourth day ; the presence of catarrh of the 
mucous surfaces, especially in the form of coryza. 

In Scarlatina the colour is bright red, and the rash is uniform, 
not crescentic ; it appears also on the second day ; the skin is very 
pungent and dry ; there is sore throat, the tongue is raw at the 
tip, or slightly furred, with red points peeping through to the sur- 
face : there is no coryza. 

In Roseola the patches are scattered, circular in form, not made 
up of crescentic portions, with intermediate healthy skin ; the 
colour is bright, and there is an entire absence of general symp- 
toms, and coryza, &c. 

SCARLATINA. 

On the second day of illness the rash appeal's on the neck and 
face, and is made up of small red dots, which crowd together, 
forming patches of various sizes and extent; after a while the 
whole surface becomes of an uniform hue ; on the third day, the 



88 ERYSIPELAS. 

eruption is seen on the body generally, the upper extremities, and 
the mucous surfaces visible to the eye; on the fourth day, the 
lower limbs are scarlet, whilst the surface is hot, dry, and harsh. 
The eruption, which maybe called a general efflorescence of boiled- 
lobster colour, is most marked about the third or the fourth day, 
and it is generally more intense in colour towards evening, espe- 
cially in the loins and flexures of joints. On the trunk it is often 
" patchy." The eruption fades on the fifth day — first on the face ; 
desquamation follows about the eighth or ninth day. 

The diagnosis between scarlatina and rubeola is the only one 
that requires notice. 

In scarlatina the rash appears on the second, in measles on the 
fourth day after the first onset of symptoms. In scarlatina the 
rash is bright red (boiled-lobster colour) ; it is not crescentic, and 
it is uniform or not patchy, or associated with intervals of normal 
integument. In rubeola the rash is of dull red colour, and it 
takes the form of little crescentic patches, with intermediate lines 
of healthy skin. The skin in scarlatina is very dry, harsh, and 
pungent. In measles this is not so marked, nor is the subsequent 
desquamation so distinct or characteristic. 

In measles the changes in the mucous membranes are accom- 
panied by secretion ; there are coryza, suffusion of conjunctivae — 
in scarlatina, the mucous surfaces are red, dry, ulcerated ; there is 
also sore throat of marked kind, but this is absent in rubeola. The 
aspect of the tongue is characteristic in scarlatina, and the pulse is 
very rapid and irritable. 

ERYSIPELAS. 

Erysipelas belongs to the domain of the general physician, and 
to skin pathology only to a slight extent, in so far as the evidences 
of the blood and tissue alteration produced by its special poison are 
shown to the naked eye. It is an acute diffused inflammation, 
ushered in by constitutional symptoms, and exhibiting itself 
locally by the presence of heat, tension, smarting or burning, 
over a surface disposed to vesicate. The local inflammation has 
a tendency to spread rapidly in extent, with more or less im- 
plication of the subcutaneous cellular tissue and the formation of 
abscess in or the occurrence of gangrene in the latter. The con- 
stitutional symptoms are : a general feeling of illness, depression, 
severe rigors, with alternate heats, thirst, quick pulse, loss of 
appetite, sometimes wandering or delirium, nausea, with pain at 
the pit of the stomach, a white furred tongue, and febrile urine, 
&c. It is usual to make two types of erysipelas. One in which the 
inflammatory action is sthenic, in which the general symptoms are 
not grave, and in which the structures, though perhaps exten- 
sively, are not very deeply implicated ; this is E. simplex. The 
other, in which the general state is grave, the structures are 
deeply (and extensively) affected ; abscess, sloughing, and gangrene 



ERYSIPELAS. 89 

are frequent ; the virus is of active quality, and the blood state 
bad. This is E. phlegmonodes. The two divisional forms are 
merely degrees of one and the Same state, chiefly influenced by two 
things — the quality of the virus and the state of the patient's 
health. 

(A.) — E. Simplex.— In this form of disease, the inflammatory 
action has its seat in the derma, and perhaps more or less of the 
cellular tissue beneath. The general symptoms are those before 
described. The local symptoms follow quickly or in two or three 
days, and commence as a burning or smarting sensation, followed 
by a feeling of tension; the surface then looks puffy, dry, and 
slightly glazed, shining ; the edges of the patch look raised, the 
part is tender and hot. In two or three days, during which time 
the redness and swelling have increased, blebs may form, of various 
sizes and shapes; these burst and dry into scabs; in live, six, or 
seven days convalescence sets in, the local changes abate in 
severity, and a yellow stain is left behind, with more or less peel- 
ing off of the cuticle. Several sub-varieties have been described, 
according to seat, aspect, and character of course. Thus there are 
— (a) E. erraticum, E. metastaticum ; (h) E. miliare, E. phlyc- 
tenodes, oedematodes ; (c) E. faciei, E. capitis, &c. &c. 

Local Yaeieties. — The most usual situation is the face (of 
course I am speaking of idiopathic erysipelas) ; it generally 
shows itself at the side of the nose, often at its root, and 
quickly spreads, with great swelling of the parts, which occur- 
rence is favoured by the presence of lax cellular tissue — e.g., 
about the eyes, lips, cheeks, and ears. The disease may 
extend to the mucous surfaces. The constitutional symptoms are 
often marked by depression, delirium, restlessness, headache, &c. 
Erysipelas of the scalp is usually traumatic ; it may be slight or 
very extensive, the whole scalp may be undermined, puffy, and 
generally infiltrated by pus, or the pus may be collected in the 
form of local abscess ; the cellular tissue of the scalp sometimes 
sloughs, and the bone gets denuded and exposed, whilst serious 
brain symptoms are often developed. 

Erysipelas of the breast is common in lying-in hospitals, espe- 
cially in women who are out of health, from, it is said, over- 
distension of the milk-ducts ; but this is probably only a predis- 
ponent. The breast looks red ; it is tender, hot, and swollen ; it 
then feels brawny, pits on pressure, gives a good deal of pain, is 
accompanied by depression of the vital powers, and terminates 
mostly in abscess and sloughing of the cellular tissue ; the glands 
in the axillse often participate in the disease. Erysipelas of the 
vulva often attacks the vulvae of lying-in women, especially primi- 
parse. In children, erysipelas, commencing at the umbilicus, is 
often seen ; particularly in hospitals. It leads to abscess and 
sloughing, and often death. When the scrotum is attacked, the 
swelling is sometimes enormous; this is produced by the rapid 



90 EKYSIPELAS. 

pouring out of serum into the interstices of the cellular tissue. 
Some call it " acute inflammatory oedema," or, when it runs on 
quickly to the formation of pus, " acute purulent oedema." 
Erysipelas of the lower limbs is a form which betokens a bad 
state of general health, and demands active stimulant and tonic 
treatment. 

Erysipelas has been observed to disappear from one, and make 
its appearance suddenly in two or more places in succession, or to 
u wander" over a large extent of surface ; in such instances it has 
been styled erratiaum. The disease is not very deep, but very 
obstinate of cure, and often periodic. 

In some cases implication of the skin is but slightly marked, 
but the cellular tissue is noticed to be much more affected than in 
ordinary cases. The skin at the seat of disease pits easily on 
pressure (is oedematous), and preserves the impress made for a 
considerable time. This is the E. cedematodes of authors, and is 
met with especially on the lower limbs of debilitated persons ; it is 
also seen on the penis and scrotum. 

(13.) — E. Phlegmon odes is, so to speak, the inflammatory form. 
The general symptoms of invasion are severe, fever runs high, 
rigors are severe, delirium is commonly present, typhoid symptoms 
often set in at an early date, and the patient is in considerable 
danger, or death may ensue. The characteristic of the local 
disease is the great rarity of the occurrence of resolution. The 
part attacked is painful, hot, tender, swollen, and very red ; in a 
day or two it becomes softish, rigors and throbbing pain announce 
the occurrence of suppuration, which may be very extensive ; the 
cellular tissue, the fascise, the intermuscular septa all partake in 
the diseased action ; the blush goes, or nearly so, but the swelling 
increases. The pus in the tissues is mostly mixed with blood and 
portions of cellular tissue. In this variety of erysipelas a change 
takes place for better or for worse about the fifth or sixth day. 
In some cases, where the virus is very active, or the patient's 
health is markedly bad, the sloughing and destruction of the 
cellular tissue may be extensive and marked : this is the E. gan- 
grenosum. The constitutional symptoms are here very severe, the 
inflamed part becomes dark-coloured, blebs appear, filled with 
bloody fluid, the general aspect of the limb is ecchymotic, and it 
feels tense at first, then boggy, puffy, and at length gives way ; 
dirty matter exudes, the structures slough, the fasciae and cellular 
tissue mortify, and the patient sinks, or recovers with great diffi- 
culty, the local mischief taxing all the powers to their utmost for 
the process of repair. 

Morbid Anatomy. — Erysipelas consists essentially in an infiltra- 
tion of the coriuin, and subcutaneous tissues in severe cases, with 
" inflammation corpuscles " (see flg. 9), which separate the consti- 
tuent elements. The blood-vessels are also much enlarged ; in addi- 
tion bullse (fig 7, chap, hi.) are formed by the separation of the 



ERYSIPELAS. 91 

layers of the rete and the horny layers of the epidermis, the cells 
of the rete being elongated so as to form fibres, which themselves 
are so arranged as to form meshes. In addition to the formation 
of bullae in the epithelial layer, and the infiltration of the corium 
and deeper parts by corpuscles (escaped white blood cells) there is 
something else. The outer and inner root sheaths of the hair 
follicle are separated by fluid effusion, which may also detach the 
hair from the papilla. The following representation (fig. 9) of 
Neumann gives a good idea of the changes above described. It 
does not show the bullse * 

Causes. — Various causes have been assigned to erysipelas. It is 
believed to be due to a special poison, which attacks those whose 
resistant power is weakened either by mental or bodily ailment. 
It attacks women more than men in the proportion of about 7 to 
4, though it is less fatal in the former ; in women, too, the disease 
is mostly idiopathic. The death-rate of 260 cases, given by Mr. 
Bird, was 7*5 per cent. The average duration of cases is from ten 
to twelve days. The disease occurs mostly in spring and autumn ; 
it is liable to occur in spirit-drinkers ; those resident in hospitals ; 
and attacks wounds. There does not appear to be any con- 
nection between the occurrence of erysipelas and derangement of 
menstruation. It has its maximum degree of frequency about the 
age of twenty, gradually decreasing till that of thirty-five (Aubree). 
Cold and moisture together are regarded as favouring its occur- 
rence ; and, on the wmole, traumatic is more fatal than idiopathic 
erysipelas. It appears that Bright's disease especially favours the 
occurrence of erysipelas if any traumatic injury be received. 

Diagnosis. — Erysipelas can scarcely be confounded with any 

* The pathological anatomy of erysipelas has been carefully studied by MM. 
Volkmann and F. Steudener (Centralblatt fur die Med. Wissenschaften, 36, 1868), 
who agree generally in the above description, believing the pus cells to come from 
the escaped white blood cells. They state that the exudation remains less abundant 
in the superior layers of the dermis. In the deep-seated parts it becomes exces- 
sive, and the vessels are enclosed by thick layers of leucocytes ; finally, large 
patches are found, which are entirely formed by the accumulation of these bodies. 
These masses sometimes present a fusiform appearance, which might lead one to 
conjecture a proliferation of the corpuscles of the connective tissue, but in their 
centre one meets with the section of a vessel. The corpuscles of the connective 
tissue do not present any essential changes. These alterations are not localized in 
the dermis, and attain their greatest intensity in subcutaneous and adipose cellular 
tissue. 

As soon as the skin becomes pale, towards the second or third day, the disap- 
pearance of the extravasated elements commences, especially in the subcutaneous 
cellular tissue ; one observes there nothing more than considerable quantities of 
cells undergoing rapid transformation into very fine granular bodies ; some hours 
later nothing more can be found than finely granular filaments. 

In the more superficial layers of the skin one observes also that the lymphatics 
are filled with granular cells of a similar nature, either pressed together or com- 
mencing to accumulate near these vessels. Bnt a small portion of the elements 
which form the infiltration may be taken up afresh by the lymphatic vessels, the 
majority die, and the most striking point is the rapidity of this process. Towards 
the third or fourth day no trace of the morbid processes is any longer to be dis- 
tingui hed in the parts previously affected . 



92 



ERYSIPELAS. 



disease, with the exception of erythema; but the general symp- 
toms, the tense, shining, smarting blush, and the implication of 
the cellular tissue, are not observed in erythema. 

The Prognosis. — The case is grave if the general symptom* indi- 
cate high fever, with subsequent prostration ; if the patient be 
old ; if the disease attacks the lower limbs ; if it occur in the scalp 
and there be diffuse abscess with depression ; if the surface assume 

Fig. 9. 




(After Neumann.) 



a . Cell infiltration of corium. b. Empty fat cells with cell growth around limiting 
membrane, c. Separated connective-tissue fibres, d. Enlarged papilla with cell- 
growth, e. Distended blood-vessels. /. A hair loosened from outer root sheath. 

a livid aspect, and present phlyctense ; if there be much vomiting 
and delirium ; if it be the phlegmonous variety, and phlebitis ensue, 
and if it be metastatic or erratic. 

The Treatment. — In treating erysipelas it is important to antici- 
pate, as far as possible, the probable amount of depression that 
will be produced by the virus action and the formation of abscess, and 
the demand that will be made by the reparative process upon the 



RUBELLA, RUBEOLA NOTHA, ETC. 93 

powers of the patient. And this can often be done. If rigors are 
severe, if there be high fever, and if the local symptoms are equally 
marked, then not only will the present excitation produce a marked 
subsequent diminution of vital power, but abscess and destruction 
of tissue will probably be more or less extensive. Then if the 
patient be out of health, if he be surrounded by bad hygiene, and 
especially if he be of good or advanced age, we must husband all 
the power he possesses. The pyrexia is treated upon ordinary 
principles; only ammonia should enter into the composition of 
our saline mixtures. A brisk purge is required at the outset. 

Should the disease be very severe, the practitioner should be on 
the qui vive for the first symptom of failing power, and treat the 
disease as tending to produce acutely a typhoid condition. Com- 
mon sense is the guide in regard to diet, wine, and medicine. 
Where the disease is less severe, sulphate of magnesia and quinine, 
or, what is better, tincture of steel, in large and frequently repeated 
doses, is the remedy 1 employ: tt[xx — TT[xxx — 3j, every hour. 
Locally it is desirable to exclude cold, apply heat, and keep the 
part covered up. In the early stage, inunction of lard subse- 
quently to painting the part with a solution of nitrate of silver in 
spirit of nitric ether is of use ; or if there be much pain, warm lead, 
belladonna, or poppy fomentations should be applied. In all cases 
early incision in suppuration, and for the relief of tension, is 
essential. 

RUBELLA, RUBEOLA NOTHA, BASTARD MEASLES, ANOMALOUS 
EXANTHEM OR ROSELLA. 

There is a form of eruption which resembles measles, but differs 
in several particulars, and about which much dispute exists. It 
was described by Dr. Babington under the term rubeola notha ; 
it is thought by others to be a roseola. The Germans call it 
rotheln. Dr. Richardson has called it rosalia. In some in- 
stances it seems to have a bright red punctated aspect, and is not 
unlike scarlatina. This is probably Hardy's erythema scarlatini- 
forme. It is common in Egypt, I know ; it is reported as having 
occurred at Malta, India, <ka. After more or less pyrexia, the 
temperature being always highest the first day of attack, and not 
exceeding 102 degrees, and ialling next day to 100, and getting 
normal the fifth day, a dusky red papular rash appears. It is 
never crescentic, but is uniformly distributed. The redness, the 
hue of which may vary, is most intense during the first day, when 
the rash is seen on the face, arms, legs, body, in succession ; there 
may be slight desquamation. There are no catarrhal symptoms, 
though the fauces are reddened. The patient very quickly re- 
covers ; there is no dropsy or renal disease following in its wake. 
The disease is held to be not contagious, or if it be so it is but 
slightly so, and it often occurs in those who have already had 



94 GLANDERS AND FARCY. 

measles. The treatment is that suited to a simple pyrexia. It 
is difficult sometimes to say to which the eruption is most allied 
in aspect, rubeola or scarlatina, but in either and all cases there is 
an entire absence of the general features of these diseases. It is 
scarcely bright enough in colour for a roseola, though it might 
very well be regarded as a roseola of dark colour. On the whole, 
then, I conclude that it is a distinct and specific exan thematic 
fever. 

GLANDERS AND FARCY. 

Equinia, or, as it is usually called, glanders, is a disease which 
originates in the horse, the mule, and the ass, and when it occurs in 
man it is communicated to him from one or other of these animals, 
either by the contact of the " discharge " of the disease with 
wounds, or by pure absorption. In the former case glanders 
commences as an erysipelatous inflammation of the lymphatics 
and glands, following quickly upon the poisoning of the wound. 
In other cases there is a period of incubation of from three to 
fifteen days. However, the introduction of this poison into the 
human subject is followed by the development of acute febrile 
symptoms, rigors, articular pains, delirium, marked prostration, 
with a tendency to gangrenous inflammation of the lymphatic 
vessels, the occurrence of a pustular and phlyctenular eruption, 
inflammation of the skin, ulceration and discharge from the 
nostrils, with subcutaneous abscesses. The above is a rough 
outline of the disease. Veterinarians describe two varieties of 
equinia, Glanders and Farcy. In the former the disease falls upon 
the nasal mucous membrane and the skin ; in the latter the nose is 
unaffected, and the skin often escapes, the lymphatics and glands 
being specially the seat of disease. Glanders may be acute or chronic. 
In the acute form there is inflammation of the lymphatics, with 
abscesses specially about the face and over the joints. Pustules 
appear over the cheek, the arms, and the thighs, and commence as 
red papules, with a distinct areola, isolated or semi-confluent ; 
these are accompanied by bullae with dark areolae. At the same 
time there comes on what appears to be erysipelatous inflammation 
of the nose, eyes, and the contiguous parts ; and soon from the 
nose a thick, viscid, often foetid humour is discharged, and if the 
nasal mucous membrane be examined, pustules and ulceration will 
be observed over its area. In the chronic disease the skin may be 
free from eruption, but the nasal symptoms are present. The 
general symptoms are the same as in the acute variety, only less 
marked. 

Farcy is either acute or chronic. In acute farcy all the general 
pyrexial symptoms of acute glanders are present, and occasionally 
some eruption occurs, but the nose escapes. The disease may 
therefore be regarded the same as acute glanders without the nasal 
affection. Inflammation of the lymphatics and subcutaneous 



FRAMBCES1A, OR YAWS. 95 

abscess are prominently marked. In chronic farcy the health 
deteriorates, and chronic indolent abscesses form about the fore- 
head, the calves, &c, giving rise to open ulcers. The disease lasts 
from a few months to three years. Acute glanders may be devel- 
oped out of chronic farcy. 

Diagnosis. — The disease commences like rheumatism, but the 
occupation of the attacked, the commencement of the disease like 
erysipelas, the prostration, the absence of joint inflammation itself, 
the pustular eruption, and the ulceration and discharge from the 
nose are significant. In chronic glanders there may be no erup- 
tion ; the disease then resembles ozaena, but if farcy be present 
the diagnosis is certain. With regard to farcy, if eruption be 
present, no mistake can occur, but difficulties do arise in chronic 
farcy without eruption. We determine the nature of the case by 
exclusion. It may resemble syphilis. 

Prognosis. — Equinia is a dangerous disease, and in acute cases 
almost always fatal. 

Treatment. — I have no experience upon this point. It has never 
fallen to my lot to treat a case of glanders. It is said upon 
good authority that the combination of arsenic and strychnine acts 
apparently better than anything else. Hyposulphites and per- 
chloride of iron have been recommended. The use of nitrate of 
silver to the eruption, and chloride of zinc solution, two grains to 
an ounce night and morning, to the nasal mucous membrane, or a 
weak carbolic acid lotion, is commended. 

FRAMBCESIA, OR YAWS. 

By general consent this disease — occurring in Guinea, America, 
Africa, and the West Indies, particularly Jamaica and Dominica — ■ 
has been assigned a place under the head of acute specific diseases. 
It is very questionable whether the disease has the least right to 
be so placed. But.pending the possession of more exact informa- 
tion as to its nature, I speak of the disease in this place. 

I am glad to be able to give the reader a good deal of information 
about framboesia, for Dr. Gavin Milroy has very courteously 
allowed me, with the concurrence of Dr. Imray of Dominica, to 
make use of an article on " framboesia, as the disease has existed 
in the Island of Dominica," which has been written by Dr. Imray, 
in reply to the series of interrogatives issued by Dr. Milroy, with a 
view to elicit reliable information on the subject of framboesia, or 
yaws, during his recent visit to the West Indies. 

My friend Dr. Bowerbank, of Jamaica, who has been in active 
practice in that island for upwards of thirty-five years, has also at 
great trouble to himself sent me a most elaborate account of the 
history, the nature, and the treatment of yaws as it exists in 
Jamaica, which I regret I cannot use in detail here, but from 
whence I shall quote a number of interesting facts. 



96 FEAMBCESIA, OE YAWS. 

The disease, called also mycosis (fungus) and jpian, according to 
all accounts is almost entirely confined to the African races, and 
was brought to the West Indies by the blacks who were imported 
thither as slaves some years ago. The white population appear to 
be exempt from the disease. Dr. Imray is disposed to think that 
this immunity may be due perhaps to absence of exposure of the 
whites to the efficient cause of the disease. Every writer indeed 
on the disease allows whites may be attacked, and Dr. Bowerbank 
tells me he has himself witnessed the fact many times. 

Characters of the Disease.— Dr.Bowerbank describes the appearance 
of the eruption as consisting at first of " small flat spots, patches, or 
blotches of a brownish or red-coloured efflorescence, .... giving the 
appearance of a congeries of the minutest blood-vessels, and some- 
times they are disposed in the shape of a halo. These spots vary 
in size from a pin's head to a pea or more. They are often 
well marked on the sides and soles of the feet and the palms of 
the hands." Tubercles follow. Dr. Imray says : " If yaws are ob- 
served as they first make their appearance on the surface, one or 
more minute whitish or yellowish points or spots will be perceived, 
not larger than a pin's head. These yellow spots are seen very 
distinctly on the dark skin of the negro. Gradually the spots 
enlarge, and begin to project from the surface, retaining for most 
part their circular form, and have much the appearance of small 
globules of yellow pus, and unless carefully examined might readily 
be so mistaken. The skin remains unbroken until the yaws attain 
perhaps the size of a small pea, but the cuticle may give way at 
any time. Then a yellowish, spongy surface presents itself, from 
which a thin foetid fluid oozes, and this spongy body continues to 
enlarge and projects considerably from the surface. Yaws are 
usually circular in form, and may be seen in the same patient of 
all sizes from scarcely more thau a pin's head to a patch one or 
two inches in diameter, and in every stage of their progress. 
Generally they are separate, but sometimes in groups close toge- 
ther, small and great. Again, they are met with of an oval form, but 
more rarely. In other cases they are irregular in shape, and so 
close together as to make one mass." 

" It frequently happens that one of these tubercles assumes very 
large proportions —one or two inches in diameter, or even more, 
projecting from the skin like the other yaws, and covered with 
yellow scabs, or having a moist yellow surface streaked with red. 
This amongst the English receives the name of 'mother yaw,' 
and in the French patois, 'maman pian.' All the other yaws 
may entirely disappear, and this mother yaw only remain ; and 
if neglected, it will degenerate into an intractable ulcer, eating its 
way into the tissues, and causing extreme and irreparable de- 
struction of the parts around, and be often accompanied by great 
constitutional irritation and extensive emaciation." 

The ordinary tubercle of yaws which forms the spongy yellow 



FRAMBCESIA, OR YAWS. 97 

growth does not itself actually ulcerate. It attains a certain size, 
giving out an ichor, then " begins to shrink, the discharge ceases, 
a yellow scab forms, and darkens as it becomes dry. From day to 
day the mass lessens, and finally the scab drops off, leaving what 
appears to be an indelible dark spot on the dark skin." 

Dr. Bowerbank also says that only a portion of the early eruption 
maturates and becomes truly tubercular, and only from some of the 
spots do fungus excrescences spring ; the typical yaw being the 
size of a raspberry, round or oval, reddish or pinkish, and firm in 
consistence. The largest excrescences grow on the lips, pudendum, 
perineum, anus, and toes. 

In Jamaica there are a number of names given to variations in 
ordinary yaws — viz., "watery yaws," "ringworm yaws," "the 
Guinea-corn yaws." The first is that condition in which the 
yaws are oedematous (watery), a state of things seen in cachectic 
subjects. In ringworm yaws the tubercles are disposed in circles. 
If yaws are small and round the disease is termed " Guinea-corn 
yaws," from the supposed resemblance to a grain of maize. Other 
terms are " master or daddy, or fadee ; " likewise " mammy, or 
mother or moder ; " and also " grandy " yaws. The first of these 
are applied to the fungus which appears during the course of the 
eruption. The two latter to the fungus which forms in the seat 
of inoculation and precedes the general eruption. There is some 
confusion here, because European dermatologists give the term 
" mother" or " mama" yaw to very large fungus growths that out- 
strip others in the course of the disease. 

Dr. Imray takes exception to the generally received description 
of yaws as not sufficiently portraying the characteristic features 
of the disease. He says : " The ordinary yaw excrescence is not 
unlike a piece of coarse cotton wick, a quarter of an inch, more or 
less, in diameter, dipped in a dirty yellow fluid, and stuck on the 
skin in a dirty, scabby, brownish setting, and projecting to a greater 
or less extent. This comparison is not so elegant as that of the 
strawberry, but I believe it to be more appropriate to the loathsome 
eruption, and more exact. It is true there are sometimes red spots 
or streaks on the yellowish surface of the yaws fungus, but this 
appearance instead of being general I have only found exceptional." 

The yaws are somewhat insensible, according to Dr. Imray, in 
their early stage. 

Seat of the Eruption, and Distribution. — The eruption, Dr. Imray 
reports, " generally breaks out in the face, the neck, the upper and 
lower extremities, the parts of generation, the perineum, the hips, 
and about the anus. They are much less frequently observed 
about the trunk, and are not so often seen on the hairy scalp. 
They may form on the nostrils where the mucous membrane joins 
the skin, and here the yaws may assume an elongated form, nearly 
closing the nostril, and hanging down on the lip." The same form 
may be observed about the eyelid. "Near to the mouth they may 
7 



98 FRAMBCESIA, OR TAWS. 

appear in such numbers and so closely set together as to form 
almost a ring round the mouth. This is especially the case in 
children. Around the anus also they sometimes coalesce and form 
one projecting circular band an inch and more in breadth." 

An attack of frambcesia varies much in severity as regards the 
size and number of actual yaws. 

Termination of the Eruption. — Dr. Imray states that in all cases 
after the disappearance of the yaws without ulceration, " a dark 
spot is left where each yaw has been and of corresponding size. 
These spots are of deeper shade than the natural black of the skin, 
and they remain for many years, but may possibly wear out in 
time. \ The skin is quite smooth, and the texture uninjured." In 
white skins the spots are of lighter hue than natural. When, 
however, the disease ulcerates scars are left. Dr. Bowerbank agrees, 
I find, in his experience with Dr. Imray. 

Should yaws not properly develop its several early stages 
the general health suffers, the patient becomes cachectic, un- 
healthy ulcerations appear over the body, especially about the 
joints, which swell and become painful, and offensive effluvia 
are given off from the body, and the attacked dies a lingering 
death, or becomes crippled, more or less, by the deep ulcerations. 

Yaws do not seem to interfere with the occurrence of or to 
modify other diseases, such as the acute febrile diseases, syphilis, 
vaccinia, according to Dr. Bowerbank. 

Unusual Forms of Eruption. — Dr. Imray notices two. In one 
the tubercles are replaced by circular scurfy spots of different 
sizes. The natives call this " dartres." The other form appears " as 
small watery-looking bodies raised above the skin, and thickly set 
together, and it is called jpian gratelle. It may occur together with 
the "pian dartres." Both are difficult to cure. May they not be 
complications only ? The "dartre" of Dominica is called "yaws 
caeca " in Jamaica. 

When the disease attacks the feet it is called tubhoe. The skin 
is very thick over the yaws, and prevents their coming to the 
surface, and thus gives rise to much pain. The growth which 
sprouts through the cuticle is called in Jamaica " crab yaw." In 
Jamaica the term membra yaws (from membra, the negro abbrevia- 
tion for remember), is applied to the few fungoid excrescences that 
sometimes show themselves in those who have had }^aws before. 

The Inoculated Disease. — Dr. Bowerbank tells me that if a poisoned 
wound be slight then little or no irritation may result, and the 
part heals. But in other instances of inoculation the wound inflames, 
and is covered with a brownish scab, beneath which is a small sore 
depressed in its centre and with raised everted edges, and giving out 
ichor. This ulcer may heal up before the general eruption appears ; 
but if large this does not happen. In any case the primary ulcer 
becomes unhealthy when the general eruption appears, and then 
f ungated. The growths then turn dark (" get ripe") and shrink, to 



FRAMBGESIA, OR TAWS. 99 

be succeeded by others. Healing may take place without scarring. 
After a while constitutional irritation occurs to a slight degree, 
the skin gets dry, particoloured, .and scurfy (yaws caeca), as if dusted 
Over with flour — caeca meaning faeces; this state lasts seven to 
fifteen days, and is succeeded by the first crop of yaws. The 
further progress is that of the disease as before described. 

Duration of the Disease. — The disease may last for years, with 
periods of comparative quiescence, instead of weeks or months. 
The usual duration is a few months — " from two to four under 
appropriate treatment." Dr. Bowerbank tells me the average 
duration is about thirteen months in severe cases. 

Constitutional Symptoms. — Dr. Imray states that there is very 
little if any constitutional disturbance at the outset of the disease. 
The attacked work, and if children play as usual. It is not until the 
disease has existed some time that the general health suffers from 
the pain and ulceration attending the disease, the sufferer getting 
debilitated and emaciated. 

Contagiousness. — Dr. Imray speaks positively of the disease 
being conveyed from person to person by contact, or the absorp- 
tion of the poison through some abraded surface, though it is not 
infectious. It attacks only those living in contact with thesalready 
diseased, and the poison may be carried from individuals by flies. 
Dr. Bowerbank remarks that the excoriations and wounds con- 
nected with scabies, Chinese itch, tick bites, leprosy, syphilis, small- 
pox, bucnemia, all render the individual more liable to the con- 
tagion of the disease, but he does not believe that the disease can 
be taken except through downright positive contact of the healthy 
with the diseased. The uncleanly are more liable to take the 
disease than the cleanly, but the healthy and cleanly take the 
disease if they are brought into direct contact with the infected. 
If one member of a family become affected, all the members sus- 
ceptible to the disease are attacked in turn. 

The period of intubation is thought to be from three to ten 
weeks. 

Sex and age make no difference as regards the liability to the 
disease. It is doubtful if it be hereditary. 

Immunity from Seoond Attacks. — A person who has passed regu- 
larly through yaws is secure from a second attack, according to 
Dr. Imray. Dr. Bowerbank speaks of persons having two and 
even more attacks, so that the idea that one attack guards the 
attacked from others is not apparently true. But there is a long 
interval between the attacks seemingly. 

Relation to Syphilis. — Dr. Imray, referring to the regular and 
definite origin and course of yaws, the immunity which one attack 
gives from a second, &c, denies its connexion with syphilis. 
Clinically speaking it could only be a tertiary form of syphilis, 
but the yaws is essentially a primary form of disease, and has no 
such antecedents as syphilis. 



100 

Nature of the Disease. — All recent observers agree that the disease 
is one sui generis. Dr. Bowerbank has long held this view I know, 
and Dr. Milroy tells me that he has no hesitation in affirming 
from what he has seen of the disease that f rambcesia, or yaws, is 
not syphilis, but a distinct and independent malady. 

The course of the disease is much influenced f r the worse, says 
Dr. Bowerbank, by bad diet and by uncleanliness. 

The Spread of the Disease. — In accounting for the recent increase 
of the disease in Dominica, Dr. Imray supposes that before the 
emancipation of the slaves every case of yaws was isolated in yaws- 
houses, and thereby the disease was kept in check, and indeed 
extinguished in some places, such as Antigua. In Dominica, 
which is very mountainous and has a scattered population, the 
scattered groups of the population have been left much to them- 
selves, without responsible medical care or supervision, and yaws has 
recently been undetected in the outlying parts of the country, and 
has gradually extended, whereas in other level islands the case has 
been different. 

Dr. Bowerbank has alluded in the papers sent me to the almost 
total disappearance of yaws from Jamaica for a series of years, 
just after the declaration of the freedom of slaves ; at least so far 
as the medical practitioners of the island seeing the disease. The 
explanation is to be found in the fact that at one time inoculation 
was systematically practised on the negroes on the estates, and 
that when the slaves were emancipated the practice ceased. He 
states that in Africa the practice is common ; parents go a long 
way to get yaws for their children from a particular tribe or place, 
and they call it " buying the yaws." The practice was put into 
operation in Jamaica, probably, by mothers to escape working on 
the estates, and in order to give them the chance of remaining at 
home to take care of their children. The lazy adult also prac- 
tised it to escape work. 

The more recent increase of yaws in Jamaica Dr Bowerbank 
believes to be in part due to the importation of the disease by 
Coolie einigrants, to the acclimatization of a species of red tick 
(bete rouge of Honduras), which is now found in the greater part 
of the island — not Spanishtown or Kingston, as yet, however — and 
which produces small sores over the body, often obstinate in healing, 
and through these sores yaw poison may find its way to the system. 
Another cause is asserted to be an increase of overcrowding amongst 
the poor, favoured particularly by the house-tax imposed of late 
years; and lastly, the entire neglect medically of yaws cases 
amongst the community generally. 

Treatment. — Dr. Imray says the treatment of yaws is as simple 
as it is usually effective in every instance if commenced at an early 
period of the disease, and if only persisted in with strict regard 
to cleanliness and attention to diet. 

In the early stage it is customary first to wash the patient, then 



DENGUE, OR DANDY FEVER. 101 

to encourage the full development of the eruption by the exhibition 
of sulphur and supertartate of potash for six or eight days. In the 
next place, mercury is to be administered, in conjunction with 
decoction of sarsa, or sassafras, or mezereum, in the f orm of tisanes, 
to which great virtues are attributed. The mercury is dropped 
directly signs of its action on the gums show themselves. Tonics 
should be conjoined with mercurials in the case of weak persons. 
Occasional aperients are also needed. The diet should be good 
and unstimulating. As regards local applications, Dr. Imray 
advises a carbolic-acid solution, or weak nitrate of mercury oint- 
ment. The natives apply the boiled and beaten-up leaves of the 
physic nut, Jatrojpha curcas / the juice of the sour orange, the 
Janipha manihot ; or the flowers of sulphur dusted over the part. 

Tubboes may be treated by paring off the cuticle down to the 
yaw or yaws, and then applying some such astringent as powdered 
alum. 

Dr. Bowerbank tells me that mercury is the active ingredient in 
all the yaws specifics — and their name is legion — used in Jamaica, 
that iodide of potassium is also efficacious, and especially if the 
disease attack the mucous membranes. 



In the East Indies, Calcutta, and West Indies, a disease called 
dengue exists. About the third day the skin gets turgid, and an 
efflorescence, beginning at the palms of the hands, gradually 
spreads over the entire body ; it is not unlike in some cases measles 
or scarlatina, of a blotchy aspect. 

The following interesting account of the rash of dengue is given 
by Dr. Charles in a clinical lecture published in the Indian Medical 
Gazette, April 1', 1872 : — 

" The Terminal Rash. --It is usual for the terminal rash to appear during- the 
course of the fourth day, and not at the end of the third The fuga- 
cious character of the eruption is one of its special characteristics. It is quite the 

role for it to be fugitive, and in this way it often evades detection In 

many cases it appears thus suddenly between the visits of a medical man, and dis- 
appearing leaves no trace behind. Very frequently an attentive nurse or observant 
mother will tell you that your patient was covered for a few hours with an abun- 
dant rash, without your being able to confirm her assertion. In no other eruptive 

fever is this the case The rash appears while the temperature of the body 

is natural In a few instances the thermometer will mark 100° F. at the 

time the terminal rash appears, but this is so exceptional an occurrence that I am 
by no means prepared to say whether in such case even this slight rise of tempera- 
ture is caused by the disease, or whether some trivial accidental circumstance may 
not have led to the slight elevation of temperature. Dengue is the only fever that I 
am acquainted with which possesses the peculiarity of the eruptive period being 

habitually without fever The rash which you saw can be very easily 

described. It was a measly rash. So very exact, indeed, is the resemblance, that 
mothers learned in the various eruptive fevers of infancy will argue the question 
with you, and insist that the child with such a rash must have measles. More 
than this, medical men who think they have special experience in measles, treat a 
succession of such cases, under the impression that they have to do with measles. 
Other medical men have told me that they had never seen measles with the same 



102 DENGUE, OK DANDY FEVER. 

attendant symptoms as those of the cases they were now treating-, and yet they 
regarded the eruption as so peculiarly distinctive, that they lulled to rest their 
doubts on the subject, and tried to persuade themselves that the disease must be 
measles. Any dermatologist, if he were shown a case in which the eruption was 
at all general, if he attempted to found a diagnosis on the characters of the erup- 
tion alone, would infallibly find himself in error, and pronounce, without hesitation, 
that the case before him was measles. I cannot tell you any means of distinguish- 
ing between the measly rash of dengue and that of measles. Not only are the 
elements of which the rash consists similar, but in many cases they arranged 
themselves on the skin in the same crescentic manner. In dengue, however, I 
have noticed that the arrangement of the irregularly-rounded patches and crescentic 
margins of the eruption is seldom so marked as in measles. It seldom begins on 
the face as in measles, and often first appears ac the root of the neck or on the 
knees, or elbows, or palms of the hands. It is sometimes quite as general an erup- 
tion as that of the best marked case of measles, but, as a rule, it is not so, and 
much larger spaces are generally met with in which there is no eruption than are 
usually left uncovered by the eruption of measles. 

" So far from constituting* a general eruption it is very often extremely limited 
in its appearance. In this case, when the eruption first came out, four inches at 
the upper part of the chest was all that was occupied by it. This is often the case, 
but more usually, even when it is limited in extent, some other part of the body, as 
one or both knees, for example, may constitute the whole surface affected by it. 

" In most of the cases which I have seen, the eruption having once disappeared, 

does not return again It is by no means uncommon for the terminal 

rash to appear as urticaria Nurses and mothers recognise this as 

nettle rash, and it possesses the usual characters of this eruption, as it occurs under 
other circumstances. 

'* Its fugitive nature is often well marked, as it may remain visible for only half 

an hour. The distressing itching it occasions is at times very troublesome 

It often proves the source of great annoyance and calls for treatment 

The itching of the surface is sometimes a very prominent symptom even in those 
cases in which no eruption has been seen 

' ' Competent observers have assured me that they have seen the eruption begin 
in the minute red points observed in measles. 

" About the termination of the rash I can speak with more confidence. In almost 
all the cases that I have seen, it disappeared entirely after remaining out for a few 
hours. In other cases I have seen it remain out for two or three days and vanish 
suddenly. I think I observed it to remain for five days in an exceptional case. 

"In several cases it did not end in this way. It gradually" declined like most 
other rashes, or even when gone left a mottling of the surface behind, not unlike the 
appearance seen after measles. This was not common in my experience, but other 
observers have told me they have met with it so frequently as to cause them to 
regard it as the rule. 

" In rare cases the hypersemia attendant on the rash is so great as to lead to 
distinct ecchymoses. I have seen the tiny elements of the eruption thus hcemato- 
graphed on the skin with vivid minuteness, and remaining distinct for many days 

after the eruption proper had gone The terminal rash you have seen 

to be one that usually very closely resembles measles, while at times the form it 

assumes is that of urticaria A third form is that of scarlatma. In my 

experience this has very seldom occurred. During this epidemic one of my medi- 
cal brethren assures me he has seen more of this form of rash than of any other. 
This quite coincides with what was seen in others of the recorded epidemics, and 
in 1853 the rash seems much more often to have resembled scarlatina than measles. 
A fourth form of rash is lichen, a fifth roseola, while sixthly, vesicles and bullae 
have been met with in this as in previous epidemics. 

"I have already incidentally mentioned that at times no terminal rash is ob- 
served. I use this expression advisedly, because the rash is often overlooked. 
.... I am confident that I have seen many cases without a trace of rash, and 
that the absence of the exanthem which we regard as a rare occurrence in other 
eruptive fevers, is very common in dengue. I cannot give you any exact idea of 
how often the eruption is absent, but I should not be a bit surprised if subsequent 
observations proved it to be absent in about a third of all the cases." 



KEDINGA PEPO. 103 

KIDINGA PEPO. 

Dr. Christie describes an exanthematous disease resembling 
"dengue." Its name signifies cramp-like pains induced by evil 
spirits. Rheumatic pains and fever are succeeded by a scarla- 
tinal-like rash, with swelling and puffiness of the face, with con- 
stipation. In forty-eight hours a remission takes place for two or 
three days. The fever generally returns on the fourth day, and on 
the fifth the rash appears, and spreads over the body in twenty- 
four hours. This is followed by swelling of the lymphatic glands, 
redness and rawness of the mucous membrane of the throat, 
lasting a greater or less length of time. The skin desquamates. 
The treatment consists in the use of quinine followed by iodide 
of potassium for the pains. Dr. Christie is the physician to the 
Sultan of Zanzibar, where he saw the disease above referred to. 



CHAPTEK VIII. 

LOCAL DERMAL INFLAMMATIONS. 
GENERAL REMARKS. 

Under the head of local dermal inflammations I include those 
diseases which partake essentially of the nature of local diseases, 
and are characterized by "inflammation," as the primary and the 
essential phenomenon. Now by " inflammation I understand not 
merely hyperemia, with engorgements of the affected parts by 
blood, so that the parts are swollen and red and hot, not only hy- 
peremia, with stasis in the vessels and serous effusion in addi- 
tion ; but also an increased activity in the tissues themselves out- 
side the vessels, and the formation of new products, or " inflam- 
matory exudation," to use a commonly employed term. The 
character and source of these new products are important items 
in this matter of inflammation. As regards the character of the 
new product, its typical features, and ultimate destination in 
marked cases are those of pus. Pus in fact is the highest grade 
of inflammation products, but pus is not necessarily formed, and 
it is held that the new products may give rise to the production 
of a tissue like connective tissue ; probably, as will be seen in a 
moment, the pus and the new connective tissue have different 
origins, and this leads me to refer to the source of the " infiltra- 
tion." It is now generally taught and believed that the new cell 
growth is made up mainly of white blood-cells, which have 
escaped through the blood-vessels ; but not only this, for it is also 
affirmed that the new cell products are in part developed by sub- 
division of the cells of the normal tissues outside the vessels, and 
particularly the connective tissue. Strieker's observations on in- 
flammation of the cornea seem to prove this, for they go to show 
that at a time prior to that at which the corpuscles of the blood 
get out of the vessels into the tissues, the actual corpuscles of the 
cornea exhibit endogenous nuclear growths, giving rise to large, 
many-nucleated cell masses. 

Very recently M. Duval* has repeated Cohnheim's experiments, 
and declares against Cohnheim's views. In the case of the mesentery, 
which Duval has examined with very high powers (1600 linear), 
he contends that in the very act of opening the abdomen of the 
frog to with draw the membrane, lymphatic sacs are opened, and 

* Sequard's Archives de Physiologie, 1872. 



LOCAL DERMAL INFLAMMATIONS. 105 

that from these a constant flow of lymph corpuscles takes place, 
which group themselves and form rows along the sides of the vessels, 
simulating the appearances that would be presented if they had 
escaped from these vessels or white blood cells. Further, M. Duval 
refers to the observations on winter frogs of Heumann, who has 
pointed out that scarcely a white corpuscle remains in the blood, 
and yet that, if inflammation be excited, corpuscles in abundance 
become visible outside the vessels, which must apparently be 
derived from the corpuscles of the tissue themselves. The elon- 
gation of the white blood cells towards the walls of the capillaries 
at certain points, M. Duval explains differently from Cohnheim. 
The corpuscles outside the vessels, he thinks, hypertrophy, a cur- 
rent of fluid from the blood setting in towards them from and 
through the vessel wall, which becomes irregular and viscous 
opposite them ; and it is at these points that the viscous white 
corpuscles within the vessels are arrested, and then elongated into 
processes. There are few, however, who will doubt that white 
blood cells do escape into the tissues. 

The next question to be determined is the disposal of, or changes 
that result in, the escaped white blood, and the proliferated con- 
nective-tissue corpuscles. In what is termed resolution the new 
growth made up of these elements in varying proportion does not 
give rise to the production of pus, but the white blood cells become 
disorganized or degenerate and are removed, whilst the connective- 
tissue cells are organized into connective tissue of a more or less 
immature kind. The degenerate cells disappear via the lym- 
phatics, which take up certain cells bodily perhaps, or more likely 
after they have undergone fatty matamorphosis. But if pus form 
the connective-tissue corpuscles give origin, it is thought, to pus 
cells no less than do the white blood cells. Therefore pus is de- 
rived, it is held, from two sources — namely, from Avhite blood 
cells, but also from connective-tissue corpuscles ; whilst the only 
source of newly organized tissue is the latter. There are three 
leading changes therefore observed in iirflammatory exudation — 
resolution, organization, and suppuration. 

The local inflammations I am about to consider are generally 
characterized by hyperemia and the presence of inflammatory 
infiltration. They are the erythemata; eczema, or catarrhal in- 
flammation ; that form which commences as a serous catarrh of the 
papillary layer, and is followed by the outpouring of sero-purulent 
discharge, as in catarrh of the mucous membrane ; plastic or 
papular inflammation, in which the inflammation is characterized 
as much by the absence of serous as by the deposit of fibrinous 
exudation ; suppurative inflammation ; and lastly, hyperemia, ac- 
companied by excessive formation of epithelial and certain cell 
growths in the papillary layer, conveniently termed squamous in- 
flammation, as in psoriasis. 

Two of these groups or classes might be separated from inflam- 
mation perhaps, and dealt with as hyperemias solely, and these 



106 LOCAL DERMAL INFLAMMATIONS. 

are the first and the last of the above named. In the former there 
is hyperseniia and serous exudation, as in erythema ; but what is 
the important thing to notice in relation to the point under discus- 
sion, there is no cell proliferation or cell infiltration in the tissues. 
If the hyperemia is persistent then there follows in due course 
hypertrophy. To avoid, however, making another group in 
classification, and pending the settlement amongst pathologists as 
to what really constitutes inflammation, I have grouped the ery- 
thematous diseases under the head of local inflammations ; the 
more so as these erythemata do in some cases run on to naturally 
well-marked inflammation. With regard to "squamous inflam- 
mation," I may say that there is here only hyperemia and hyper- 
plasia or hypertrophy, and no actual inflammatory infiltration. 
Psoriasis, the type of the class, is on the border-land only of in- 
flammation; but I group it under inflammations for the present 
at all events. 

The reader will very naturally want to be told wherein lies the 
difference between hypertrophy and hyperplasia following hy- 
perseniia, on the one hand ; and the changes that occur in the skin 
in zymotic diseases, and those that are observed in lupus, syphilis, 
and leprosy on the other hand ; and what are the differences that 
lead dermatologists to make the special class of diseases to be 
dealt with in detail in this chapter. In the first place, with regard 
to the local changes in the zymotic diseases — as small-pox and 
typhoid — these are only parts of a general malady, and could not 
be regarded in a group characterized essentially by peculiarities 
of local change. From an etiological point of view it would be 
impossible to do so. Then, in regard to lupus, syphilis, &c, there 
are certain anatomical characters and behaviours about the 
growths, which, no less than peculiar concomitants of associated 
constitutional states and the like, that mark them as belonging to 
a special class of neoplasmata or heterologous new formations. 
In regard to the distinction to be drawn between hyperplasia con- 
sequent on inflammation, and hypertrophy, as Rindfleisch hints, 
the latter is much slower, even if the etiology be left out of view ; 
and I should add, there is in the one the escaped blood cells de- 
veloping into the new tissue, and in the other the increased supply 
of blood and transuded serosity. But the two have certain analo- 
gies, and it is difficult if not impossible to draw a line between 
hypertrophy and inflammation. But further, it may be said — and 
this applies to tumours and special neoplasms, as lupus and syphi- 
lis — whilst the inflammatory infiltration is caused by some irri- 
tant, the tumour or heteroplastic neoplasm arises spontaneously, 
or from a specific cause acting generally and modifying nutrition. 
There is with inflammation the accompanying heat, redness, pain, 
and swelling, and these " signs " acutely developed ; there is 
less tendency to spontaneous cure with tumours ; and lastly, the 
inflammatory exudations directly tend to the formation of pus. 



ERYTHEMA. 107 

ERYTHEMATOUS DISEASES. 

The diseases which rank under this head as having simply erythema 
as their primary and only feature are exceedingly simple and well 
denned. They are three : erythema, roseola, and urticaria. Willan 
placed these with the acute specific diseases, under the term exan- 
themata. But though they are pyrexial, and the result, as regards 
the eruption, of a disturbance of the normal state of blood, yet 
they do not run so definite a course ; they do not depend upon so 
specific a cause in each case as the exanthemata, and they are not 
like them contagious ; hence they form a separate group. These 
erythemata are characterized mainly by the occurrence of active 
hypersemia of the longitudinal plexus of the skin (erythema), and 
its immediate consequences — ex., serous effusion — nothing more. 
In other diseases hyperemia is present, but then it is the insigni- 
ficant element in the morbid processes ; the sqnamation, the exu- 
dation of serosity, together with the formation of crusts, the 
hypertrophy of the papillae, the morbid cell-growth present from 
the beginning of disease and not as a mere secondary occurrence, 
all indicate peculiar alterations in the behaviour of the tissues, 
which cannot be explained by the mere presence of hypersemia. 
In erythematous diseases the redness may be rosy (roseola), or 
bright red (erythema and urticaria) ; in urticaria " wheals " (see 
Elementary Lesions, p. 29) are present. The erythema in these 
diseases is removable by pressure. Unlike the more common 
eruptive diseases of the skin, the erythemata exhibit the closest 
connexion between local and constitutional phenomena. Febrile 
symptoms antecede and are relieved by the development of the 
erythema in the exanthemata, showing that the local skin- 
changes are secondary, and only parts of a general disturbance 
which is primary. I have referred to those forms in speaking of 
erythema as a lesion (see p. 28). I also have included under this 
head sections on follicular hyperemia, pellagra, and certain 
medicinal rashes. 

I. ERYTHEMA. 

Erythema is a superficial inflammation of the skin, occurring 
in slightly raised patches, diffused or circumscribed, of varying 
size, rarely exceeding, however, three or four inches, and generally 
much less. The redness disappears at once by the pressure of the 
finger, but returns instantly on its removal ; it is accompanied by 
slight swelling, simulating papulation or slight tuberculation from 
exudation of serosity — the escape of which is explained by the 
obstructed capillary circulation — heat, and. itching. The disease 
ends in furfuraceous desquamation with slight staining. The 
general symptoms are slight — i.e., mild fever, headache, quick 
pulse ; but they may be practically nil. 

The varieties of this erythema eruption may be divided into two 
groups — (A), local or idiopathic, induced mainly by local irritants ; 



108 ERYTHEMA. 

and (B), symptomatic, including the erythemata which occurs in 
parts of other and general diseases. In ihe former the disease is 
merely hyperemia, without much if any appreciable effusion into 
the cutis and cellular tissue ; in the other there is more escape of 
serosity from the vessels, and hence greater prominence of erup- 
tion. Hence the two groups have been designated respectively 
after Hebra, erythema hyjiercemicum and erythema exsudativum. 

Group I. — Idiopathic or local : includes erythema simplex, E. in- 
tertrigo, E. Imve. Erythema simplex is produced by the irritation 
of external agencies, such as friction, stings, heat, the contact of 
acrid fluids, plasters, medicinal inunctions, and stimulating appli- 
cations of all kinds. There is redness, diminished or dissipated 
by pressure, returning on the removal of the finger, without sensi- 
ble swelling, except in E. lseve, when it is due to the dropsy always 
present, but a sense of heat, and variation in colour according to 
the activity of the general circulation. The slightest forms of 
burns would rank under this designation of E. simplex. Chilblains, 
or pernio, is another form of erythema caused by cold. 

Erythema intertrigo, or simply intertrigo, is the name given to 
the redness which is produced by the friction of two folds of 
delicate skin, especially in fat persons and children : this is seen . 
in the groin, axilla, neck ; sometimes the irritation causes the 
exudation of a fluid, partly perspiration, whose acridity increases 
the local mischief,, and presently an offensive raw surface is 
produced, giving out a muciform or puriform fluid (the ery- 
thema purifluens of Devergie). The same disease is seen about 
the prepuce and the vulva. Intertrigo is particularly seen 
in lymphatic subjects. It simulates eczema; but the origin 
is evidently from the friction of two surfaces ; the secretion 
is not that of eczema, it is thin, muciform, stains but does 
not stiffen linen, and results from a mucoid degeneration of 
the tissues. Hardy correctly describes the disease produced by 
the inunction of mercurial ointment as a vesiculo-pustular ery- 
thema ; in which upon red patches, little vesicles (or puriform 
vesicles) appear, quickly rupture, desiccate, leaving behind an 
erythema, whose surface desquamates : the disease subsides in a 
week or ten days. It differs from eczema, in its acute course, and 
the character of its secretion, which is clear, not viscid, and does 
not stiffen linen, as in eczema. 

E. Iceve, is the name given to a blush of erythema, of greater or 
less extent, which is seen over cedematous parts, especially on the 
front of the legs in dropsy. The skin may slough and become 
gangrenous at the seat of the blush. The redness which precedes 
the formation of bed-sores receives the name erythema para- 
trimma. It is caused by the pressure of constant lying when the 
system has lost much of its tone, as in fevers and other lowering 
diseases. 

I have met with several examples of erythema of the hands 



ERYTHEMA. 109 

produced by contact with dyes. In the early part of 1870,* a man, 
aged twenty-eight, foreman in a cheap kid-boot shop, presented 
himself to me with hands red and swollen in different places from 
the action of the dye of the kid boots, made of sheep-skin, which 
the man was in the habit of trying on " all the day." The disease 
first commenced in the fourth finger of the left hand, which 
" swelled up and felt hot, stiff, and tender." The redness then 
extended to the knuckles and the front of the hand. When I 
first saw the case the hands were much swollen, so that they 
could not be closed ; the fingers looked large ; the redness was 
patchy. In the left hand it was well marked . along the outer 
and palmar side of the little finger and the outer edge of the 
palm ; also about the third finger. In the right hand the redness 
and swelling were most distinct about the thumb at the part which 
opposes the fingers, and the skin here looked just as though it 
were going to blister ; it felt hot, and throbbed a good deal : in 
fact, the parts of the hand principally affected were exactly those 
against which the boots rubbed in the act of their being tried on 
to the customers' feet. There was no doubt from inquiry that 
the dye of the boots caused the disease. Rest for a few days, an 
oxide of zinc lotion constantly applied, and saline aperients in- 
ternally, soon restored the parts to their healthy condition. The 
man returned to his occupation soon afterwards and had a recur- 
rence of the erythema, which he has since prevented by shielding 
his hands in his occupation with gloves. 

I also had under my care about the same time a similar case in 
an inspector of clothing, whose duty it was to examine the cheap 
black and blue cloths used in a certain establishment connected 
with the public service, he doing so in a manner that necessarily 
caused considerable friction of the cloth against those parts of the 
hand that were inflamed. 

Passive erythema results from mechanical obstruction to the 
passage of blood through the veins by tumours, ligatures, gravita- 
tion, inaction of the heart, varicose veins, and the like. In these 
cases the colour of the redness is bluish or dark ; the erythema is 
removable by pressure, but tardily returns, and the part affected 
is often sensibly cold and swollen. 

Group II., or Symptomatic Erythema. — Under this head rank 
those hyperasmias which are the consequence of a more or less 
general pyrexial state. In all of them there is malaise, headache, and 
quick pulse, pains about the joints, and disordered bowels, a day or 
two before the eruption appears. This assumes different forms, and 
Hebra has included all these under the one term erythema multi- 
forme. In England we specify E. jpapulatum, tuberculatum, nodo- 
sumfugax, marginatum, and circinatum. The first three of these 
are stages the one of the other, and during their course the redness 
assumes a bluish tint, and fades away insensibly into the sur- 

British Medical Journal, Feb. 5, 1870. 



110 ERYTHEMA. 

rounding skin. In E. papulation, small red spots, varying in size 
from a pin's head to a split pea, appear; at first they are not 
raised, but presently become papular, of more vivid colour, pale on 
pressure, and die away in a few days with slight desquamation. 
These spots may be aggregated or separated, and are seen espe- 
cially on the back of the hand, the arm, neck, and breast. The 
disease lasts about three weeks, and seems to be associated with 
rheumatic symptoms. It occurs mainly in young people. E. tuber- 
culatum is the same disease in which the erythematous blotches 
become somewhat tuberculated. It is seen in servants who make 
a change of residence from country to town. E. nodosum is a more 
marked stage of the last noticed ; the spots are larger — as large as a 
nut or walnut, even attaining a diameter of two or three inches, the 
long diameter being in a majority of cases parallel to that of the 
limb, oval. They are generally seated on the anterior aspect of the 
leg, very rarely indeed on the arm, and rarely above the knee. The 
swelling is raised, slightly hard, painful, and evidently accompanied 
by tumefaction of the cellular tissue ; the redness, at first vivid, 
but not so defined or limited as in E. papulatum, presently 
becomes purplish at the circumference and paler in the central 
part, dying away like an eechymosis. The patch also softens and 
often simulates fluctuation, but it is said never suppurates. Chorea 
and rheumatism are associated sometimes with this form of 
erythema. It is uncommon after the age of twenty, and appears 
to be connected in some way with adolescence. It is believed 
that a thrombus is the starting-point of this, and perhaps the other 
varieties of erythema. It is generally accompanied by pyrexia 
and rheumatic pains. I have seen erythema nodosum occur in 
conjunction with the other varieties above named. E.fugax, is simply 
patchy-redness, which quickly disappears, and is capricious in its 
character This variety of erythema is noticed in persons of 
irritable habit, in those who are suffering from any digestive or 
assimilative derangement (especially in females) — e.g., from dys- 
pepsia, muco-enteritis, uterine, hejDatic, or renal disease of sub- 
acute character. The erythematous patch is red, but tender, 
fading and desquamating, and accompanied by more or less pyrexia. 

Should erythema occur as a circular blush, with an unaffected 
centre, it is called E. circinatum ; and if it have a well-defined 
circumference, E. marginatum, I should imagine that these two 
latter are unworthy of separate names, and are often the erythema- 
tous stages of parasitic disease, tinea circinata, and especially in hot 
seasons, of chloasma. Hardy describes an erythema scarlatini- 
forme that has been referred to under the head of rubella or 
anomalous exanthem. 

Acute diseases, especially at the time of convalescence, often ex- 
hibit a slight access of febrile disturbance, and after a little itching 
and local heat, red patches appear about the limbs, thighs, buttocks, 
neck and face. These patches vary in size from that of a pea, 



EEYTHEMA. Ill 

to that of the palm of the hand. They are vivid red, last a few days, 
and then fade with desquamation. They are frequently an accom- 
paniment of thrush. Hyoscyamus, belladonna, and copaiba give 
rise to erythemata, which will be noticed under the head of me- 
dicinal rashes, and lastly, after surgical operations red rashes 
occur: these are generally roseolous ; they may be erysipelatous, 
or indicative of pyaemia. 

Erythema Gangrenosum. — In persons who are reduced by de- 
bilitating disease, patches of dull erythema may occur here and 
there, and instead of the reparative process being properly carried 
on, the part may slough and become gangrenous. This one 
readily understands. In many cases patches of purpura are the 
starting-points of the gangrene. Mr. Wilson records a case in 
which calcareous solidification of the arteries was found after death 
in explanation of the case. The affection has been named erythema 
gangraenosum. A good case has been recorded by Dr. Hilton 
Fagge."* The patient, a man est. fifty, was admitted into Guy's Hos- 
pital, on April 23d, suffering from difficulty in holding his water 
double phthisis, and great emaciation. He complained of a 
feeling of tightness in the calves of the legs, and pretty soon pur- 
puric spots appeared about the knee, which felt stiff. On the 29th 
the patch on the left knee, about 1-J- inch long, appeared to be 
formed of dead skin, surrounded by a deep purple line. A patch 
on the right knee presented the same appearance. During the 
next few days the centres of the gangrenous spots, which were quite 
insensible to pricking, &c, assumed a yellow aspect, whilst fresh 
gangrenous places developed in the site of other apparently purpuric 
spots. There were purpuric places on the arms, but surrounded 
by a slight red halo. The patient died on the 21st of May. The 
post-mortem disclosed the usual signs of tubercular disease of the 
lungs, but also ulceration of the intestine and disease of the 
mesenteric gland. It will be observed that the disease was sym- 
metrical, and that the skin changes consisted in dry gangrene. Dr. 
Morley Rooke, in 1864, described a case in which he believed spon- 
taneous gangrene occurred. But I think the disease in his case is 
different in aspect from true gangrenous erythema, yet the case is 
worth mentioning. The patient was a lady, unmarried, good- 
looking,' hysterical, of general good health, with vivacious manners, 
and aged thirty-nine. After an attack of feverishness and hysteria, 
she began to betray very capricious tastes and tempers towards 
everybody with whom she had to associate. On the fourth day a 
small red patch appeared below the left mamma, in the sulcus 
between it and the ribs, 1^ inch by 1 inch in size. The patch was 
not elevated, but there was some pricking sensation in it. For 
two or three days things remained in statu guo, then suddenly a 

* Guy's Hospital Reports, Jan. 1868. Another case will be found recorded by 
Brodie, in his works, vol. iii, 392, 



112 ERYTHEMA. 

good deal of redness overspread a large portion of the mamma, and 
in the course of the following day, a white patch, the size of a 
shilling, Hat, smooth, painless, was observed in the centre of the 
blush, and in the next twenty-six hours this had enlarged to the 
size of half an orange, the cuticle having become loosened at one 
part, and the skin beneath as white as, and about the colour and 
appearance of, a smooth layer of firm wax or tallow (being in- 
sensible and dead). No bullae nor vesication occurred. Patches 
next appeared in symmetrical order over different parts of the body 
for four months ; after a time irritation of the kidneys and bladder 
set in, &c. Now this form of disease was wholly different from 
true gangrene of the skin. There was, in the first place, an entire 
absence of any general enfeebling condition sufficient to account in 
any degree for the occurrence locally of gangrene — nay, the patient 
was in good health. The erythema, at its first occurrence, was 
attended by active hypersemia, it was of good colour, and the repara- 
tive process was active. The co-existence of gangrene due to a 
general lowering of vitality and of activity in the local circulation 
with rapid repair, involves a manifest contradiction the one of the 
other. On this ground alone I deny that the affection was produced 
naturally. Then, on the other hand, suppression, not merely reten- 
tion of urine, appeared in three weeks, together with cystitis, severe 
vomiting, &c. — symptoms at once referrible to the absorption of 
cantharides, and its action upon the urinary organs ; hence the 
bloody urine. In addition, the patches of disease sometimes only 
reddened, and did not slough. Then the rajDid destruction of tissue, 
the general symptoms bearing no sort of relation to (wholly unac- 
counting for) such kind of destruction; the evident attempt to 
conceal the early erythematous stage of disease ; the healthy 
healing of the sore ; the non-assumption by the bed-sore of the 
characters of ulcers elsewhere (supposing the blood to be under 
the influence of a special poison) ; the period of repose assumed by 
the disease, its long course, the moist aspect of the slough (being 
quite different from that produced by blood poisoning, and exactly 
that produced by local applications), and the marked hysteria of 
the patient ; all point to an artificially-produced disease, and so I 
feel sure it was. When erythema is followed by gangrene, there 
must be a sufficient lowering of vitality to account for local death, 
unless immediately induced by purpura, by embolism, or by 
obstructed arteries. 

Prognosis of Erythema. — Erythema when it becomes chronic is 
a source of great discomfort ; in the more marked forms the 
disease lasts two or three weeks. In E. lseve and E. paratrimma, 
the prognosis is that of the general malady present. 

Diagnosis. — Erythema is known by its superficial character / the 
redness disappearing by pressure ; by the peculiar change in the 
colour of the circumference of the patch from bright red to 
purple during resolution, the absence of marked itching, heat 



ERYTHEMA. 113 

or burning, by the general circumscription of the 
patches, their little tendency to spread, and their but slight 
elevation. Erysipelas differs in the shiny, hot, burning, tense, 
blushy swelling, the rigors at the onset, their tendency to spread, 
and the implication of the cellular tissue, together with the deep 
(non-rosy) red hue. Urticaria is known from erythema by the 
peculiar stinging sensation, by the presence of wheals, which form 
and disappear in a wondrously capricious and sudden manner ; by 
the irritability of the skin, easily detected by the red line which the 
nail or slight friction at once brings out, or the rapid springing up 
of a wheal in the spot irritated. Roseola is something like E. 
papulatum, but the general symptoms are especially pyrexial in 
the former, rheumatic rather in the latter ; the eruption of roseola 
is rosy or pink and of a defined character, often punctate ; ery • 
thema is generally a partial, not a general affection like roseola. 
Erythema papulatum may resemble lichen urticatus, but in the 
former the papules are primary, and the disease runs an acute 
course and is not seated about the trunk ; in the latter w r heals are 
present and papules arise out of wheals ; the disease is chronic, and 
the skin generally is irritable and is the seat of stinging and itch- 
ing, especially at night, and the trunk is specially affected. 

Treatment. — In the case of the local or idiopathic erythemata I 
first of all remove all irritants, pay especial attention to cleanliness, 
and merely apply soothing agencies, prevent friction, and use zinc 
ointment, or glycerine and rose-water, or the linimentum aquse 
calcis, or fine starch, or lycopodium powders. It is better to avoid 
poultices. All that is further needed is to give aperients inter- 
nally. In intertrigo I adopt the same plan of treatment in mild 
cases. Sometimes intertrigo becomes a troublesome disease, with 
sour, acrid discharge, which irritates the parts around and induces 
even excoriation ; the disease then is generally aggravated by some 
internal derangement, whose type is muco-enteritis. In these 
cases, alteratives, with chlorate of potash in the first instance in- 
ternally, are of service, particular attention being paid to diet ; 
such food as corn-flour, maizena, and the like must be forbidden, 
and proper nutritive substitutes (Hard's food or Robb's biscuits) 
be given to children in conjunction with a suitable quantity of milk. 
Then locally, zinc ointment, starch powder, bismuth lotion, zinc 
lotions, or a calamine lotion may be used (see Formulae Nos. 39, 
40, 45, 76, 77, 117) ; and lastly, if chronic, w r eak solution of nitrate 
of silver may be used ; syrup of iodide of iron and cod-liver oil are 
also indicated in strumous subjects. 

In the erythemata dependent upon general causes I always 
remember the effect of ingesta ; that a gouty or rheumatic habit, 
disordered menstrual function, dentition, delicacy of skin, or lym- 
phatic temperament, are present in greater or less degree. It is 
important to allow T the patient the use of an unstimulating diet 
only, to forbid him or her spirits, wine, and beer, to clear out the 
8 



114: ROSEOLA. 

bowels, and in the early stage to adopt a soothing regime, with tepid 
sponging, and emollient baths. Tonics are generally demanded 
later on in the case. If there be any distinct rheumatic symptoms, 
I always increase the renal secretions, get the liver to act by 
aperients, and then give colchicum (in acute cases) and iodide of 
potassium with bark and ammonia. In E. nodosum, aloes and iron 
in combination are very useful in the fat, bloated, full-coloured, 
but flabby and stunted lymphatic subjects that are often affected. 
Locally, the use of an alkaline lotion is all that is needed. Anaemic 
people of course need iron. 

In all cases, if there appear to be an overloaded yet anaemiated 
state of system, I mostly combine (saline) aperients with prepara- 
tions of iron ; and any neuralgic tendency should be met with 
quinine. 

Bed-sores are best treated by attempting to " harden " the skin 
in the early state by spirit applications, removing pressure as much 
as possible at later stages by pads, cushions, and water-beds, and 
by using charcoal poultices or soap plaster spread on soft leather 
to the sores. For chilblains, equal parts of turpentine and tinc- 
ture of aconite or belladonna, and soap liniment, together with 
tonic treatment, iron, quinine, and cod-liver oil, constitute the 
best treatment. 

II. ROSEOLA. 

It is important to know this disease — not so much because it 
gives rise to any anxiety or trouble, as that it is likely to be con- 
founded with measles and scarlet fever. The disease — roseola — is 
non-contagious, is accompanied by some fever and by a rash, 
not much raised above the level of the surrounding part, but of 
rose colour. It is in fact an erythema of a rosy hue. The eruption 
is patchy, and its colour deepens somewhat as the disease advances. 
It is accompanied by slight itching and sensation of heat. It is 
not preceded by any marked signs or symptoms of catarrh, but 
only slight redness of the mucous surfaces of the palate and 
fauces. 

Roseola is divisible into two groups, Idiopathic and Symptomatic. 
In the latter group the roseola occurs as an accidental phenomenon 
in the course of acute diseases, and hence is called symptomatic ; 
in the other group it exists as the sole and primary disease. 

Idiopathic Group. — Roseola infantilis is the name gi ven to rose- 
ola when it is seen in infants. It roughly resembles measles with- 
out the catarrh ; it runs an irregular course as regards precursory 
symptoms, which vary in degree, and in the extent, degree, and 
seat of eruption. Now, it is pretty general but patchy, now, 
limited to the arm, or the neck, or trunk ; the rose-blushes often 
come and go for several days capriciously, and are accompanied 
by local heat and itching, which are often marked at night. The 
catarrhal symptoms of measles are, as before indicated, absent. 



ROSEOLA. 1 1 5 

The patches are about half an inch or so in diameter. The redness 
generally lasts a dozen or more hours. R. cestiva is simply ordinary 
roseola occurring in the summer time. The very same eruption 
occurs in the autumn, and is generally seen in children on the 
arms and legs, in the form of circular blushes, about half an inch 
in diameter, and of a dark hue ; but it is named the R. autumnalis. 
When the disease assumes the form of rings (and this is generally 
observed about the buttocks, thighs, and abdomen), developed 
from little rose spots, and enclosing presently a healthy circle of 
skin, an inch or so in diameter, the variety R. annulata is present. 
The concomitant symptoms are the same as those of the R. gestiva. 
It is' absurd to make these varieties. 

The Symptomatic Group contains roseolas which are merely rosy 
erythemata developed in the course of acute diseases, generally 
appearing about the arras, breast, and face, thence spreading over 
the body. R. vaccinia co-exists with the formation of the vaccine 
vesicle, and is accompanied by slight fever. It commences around 
and about • the seat of the vaccination. In cases of fevers, about 
the tenth day or so, and indeed whenever the weather is very 
warm, the perspiration is apt to distend the sweat glands, which 
become more or less hypersemic, so that little vesicles form, i.e., 
miliaria and sudamina. Sometimes red blushes accompany this 
particular kind of vesicular eruption, and to these rosy blushes 
the name R. miliaria* has been given. It is the R.febrilis of 
authors. So in regard to acute rheumatism and cholera, the 
rose rash has been termed R. rheumatica and cholerica, but it will 
be evident that these varieties of roseola are simply items of 
particular diseases divorced from their true place and connexion 
as parts of the descriptions of those several diseases. 

After surgical operations a rash like scarlet fever very frequently 
occurs ; its colour varies somewhat ; it is not contagious, and is 
without the general symptoms, the throat complication, hot skin, 
quick pulse, and tongue of scarlet fever. It is due, no doubt, to 
some volatile poison free in the blood. It has no gravity. 

Little is known as to the cause of roseola. The causes, accord- 
ing to some, are legion — heat, cold, ingesta, irritation of delicate 
skin, gout, change of season, acidity, &c. 

The Prognosis offers no point of gravity or interest. 

The Diagnosis. — Roseola is likely to be confounded with 
rubeola, scarlatina, urticaria, erythema. It is known from measles 
in that it possesses no catarrhal symptoms ; in that there is no 
relation between the febrile symptoms and the amount of erup- 
tion ; in that there is no epidemic influence at work in its produc- 
tion ; in that it is irregular in its distribution, non-crescentic, not 
uniform, not dark-coloured ; but irregular, rosy, and often com- 

* Some further remarks in reference to miliaria will be found under the head of 
diseases of the perspiratory glands. 



116 UKTICAEIA IN THE ADULT. 

mencing in other parts than the face. Rubeola has a regular 
course, and is not partial in regard to the distribution of its 
accompanying eruption. 

It makes very little difference if roseola be confounded with 
erythema, for the one is a red, the other is a rosy erythema. 

In Scarlatina, the general aspect of the disease is grave ; the 
fever is marked, the throat is bad, the tongue is peculiar ; the 
skin harsh, dry; the rash general, punctiform, boiled-lobster like. 
The progress is more uniform, and the disease can be traced to 
contagious or epidemic influence. 

In Urticaria, the diagnosis is at once settled by the discovery or 
production of a wheal, and the peculiar stinging character of the 
local irritation, with the capricious character of the eruption. 

The Treatment consists in that which is merely tentative : so far 
as general measures are concerned, in giving salines, aperients, 
laxatives, &c, and treating any special symptoms. Locally, in 
removing all causes of irritation — e.g., irritated and tender gums, 
by lancing; acidity of stomach, by magnesia, soda, or lime- 
water; intestinal irritation, by "alteratives," such as grey 
powder, rhubarb, and subsequently tonics, keeping up the warmth 
of the surface, and if possible, bringing on perspiration. The sur- 
face f-hould not be chilled. My general plan is to give salines 
with a.amonia, followed up by a mild aperient, and then quinine. 

III. URTICARIA, OR NETTLE-RASH. 

This disease — urticaria, or nettle-rash — presents certain peculi- 
arities according as it occurs in the adult and the child, owing, in 
the latter, to the greater sensitiveness of the skin, and the 
tendency to the deposition of lymph in the site of the wheals. 
Hence I shall, on clinical grounds, treat of urticaria in the 
adult and urticaria in the child. The reader will understand 
that this division is adopted for convenience only. I wish also 
to say that I hold urticaria to be essentially neurotic in 
origin, and should have classed the disease under the head of 
neurotic diseases if we possessed a little more certain know- 
ledge as to the exact part which the nerves play in its genesis ; 
for the present I retain it amongst cutaneous hyperemias. 
Urticaria, moreover, has its affinities to the hydroa of Bazin, to be 
referred to under herpes. I will now describe 

A. URTICARIA IN THE ADULT. 

This is a febrile and non-contagious disease, in which 
hypersemic elevations, similar to those that follow the sting of a 
nettle (urtica), are produced upon the skin. The symptoms are 
general and local. When the disease is well marked there is more 
or less fever, quick pulse, dry skin, headache, malaise, mostly pain 
at the pit of the stomach, and often irritation of the mucous 
membrane of the intestinal tract, whilst on the skin appear what 



UKTICAKIA IN THE ADULT. 117 

are termed wheals or pomphi ; the development of these wheals is 
accompanied by tingling and burning ; the wheals suddenly come, 
and almost as suddenly go, without leaving any stain behind, or 
being followed by desquamation. The eruption may attack a 
small part of the body, or the wheals may spring up quickly in 
succession over a much larger area. Wheals have been described 
in part at p. 29 : their tint may be rosy, but more generally it is 
whitish. These wheals vary in size and shape ; they may be 
linear, band-like, irregular in outline, or oval; the white centre, 
which feels hard and raised, may be small, and the red halo large, 
or a large red patch may whiten at two or three points in its area. 
In all cases the accompanying sensation is a hot, tingling, burn- 
ing one. Wheals are evoked readily by scratching. The skin 
generally is remarkably sensitive, and the application of any 
irritant is followed by the production of redness or even wheals ; 
so that it is possible by using the nail of the finger to write one's 
name or to draw figures on the skin, and these are marked out by 
red lines or wheals produced at the seat of the scratchings. 
Sometimes the formation of wheals is attended by abundant 
effusion of serosity, but this happens where the texture contains 
much lax cellular tissue. The disease attacks persons of every 
age, and most frequently in spring and early summer perhaps, 
whilst it may also be intermittent or periodic. 

A number of varieties of urticaria are made by writers. I think 
only two need be made — viz., acute and chronic. 

Acute Urticaria. — In this variety there is more or less fever, 
together with marked symptoms of stomach derangement, such as 
nausea, white and dry tongue, thirst, quick pulse, headache, and 
general malaise. I have noticed in most cases a rosy blush about 
the face. The itching and stinging sensations accompanying the 
eruption of wheals, which are scattered, are well marked and 
intensified at night. The skin generally is irritable, and wheals 
readily spring up when it is irritated. This, the typical form of 
the disease, has been called urticaria febrilis / when it has been 
caused by some error of diet, it has been styled U. ab ingestis / 
and when the wheals are more closely than usually packed 
together, U. conferta. But urticaria febrilis includes these two sub- 
varieties. In those cases in which errors of diet excite the 
disease, the latter may occur in a very severe form, and the patient 
seems as if poisoned. There is high fever, vomiting, headache, 
quick pulse, and delirium, whilst the mucous surfaces are hot, 
irritable, and tingling, and the conjunctivae implicated. Pre- 
sently the face rapidly swells, so that the countenance is com- 
pletely masked ; the ears, nose, eyes, and lips are swollen, and feel 
hot and tingling. The mucous membrane of the larynx is 
evidently affected. The swelling speedily subsides and travels to 
the body and trunk, and this very rapidly. The eruption is 
accompanied by intolerable itching, and the formation of wheals 



118 URTICARIA IN THE ADULT. 

is attended with alleviation of the general symptoms. Desquama- 
tion to a slight extent succeeds to the phenomena described. The 
substances that generally act as excitants of tins acute eruption 
are shell-fish (especially mussels), pork, prawns, lobsters, oysters ; 
but eggs, fruit, rice, raspberries, strawberries, mushrooms, cucum- 
bers, coffee, &c, and the generally harmless articles of diet, in 
certain subjects, induce it ; and so may valerian, copaiba, &c. 

In some cases the formation of wheals is accompanied by such a 
free outpouring of serosity that the cuticle is uplifted into blebs 
or bullae, and this has been termed urticaria bullosa, but the 
reader should refer to this disease under the head of herpetic 
diseases (Hydroa). 

Chronic Urticaria. — The chronic forms may result from the 
acute, or develop out of a state of tolerable health, and without 
apparent cause. There is little pyrexia present in chronic urti- 
caria. When the crops of wheals are of pretty long continuance, 
the disease is called U. jperstans. In other cases the wheals are small 
and very fugitive ; but the skin is irritable and the itching 
intense. This is U. evanida. The name factitious urticaria has 
been given to that form of the disease which is easily produced by 
mechanical irritation, and is not idiopathic. 

In persons broken in health, especially by intemperance, the 
urticated patches are raised, in consequence of the implication of 
the subcutaneous cellular tissues into patches about the size of a 
nut or walnut ; these swellings show themselves on the limbs, 
and possess the especial feature of urticaria — viz., quick appearance 
and disappearance, or intermittence. This is called U. tuberosa. 
Some cases of the kind are recorded by Fouquet* and by Perroud,f 
the latter styling the five cases he gives " ephemeral congestive 
tumours of the skin." The former treated the disease in women, 
and declares that it is connected with disorder of the sexual 
functions, pregnancy, or lactation; the latter says that those 
attacked first feel, in that portion of the skin in which the 
swelling is to appear, a sudden abnormal sensation — either a sense 
of coolness, of tension, of tickling, or of slight pain. In a few hours 
a hard, hot, indolent, pale-reddish or colourless swelling appears, 
and may attain the size of a turkey's egg. There may be more 
than one tumour. In a few minutes, or a few hours, the swelling 
or swellings entirely disappear, leaving the skin in a normal condi- 
tion. Perroud associates the disease with uterine disturbance. 
In some cases there is swelling and apparent oedema of the cellular 
tissue — now here, now there ; but the wheals are more or less 
scarce and occasional. The redness, the heat, the tingling, and 
swelling exist, but it is only the accidental appearance of the wheal 
that discloses the true nature of this variety, called U. subcutanea 
(Willan), or cedematosa (Hardy). Even here capriciousness is 

1863. f Annales de Dermatol, et de Syphilis, 1, 3. 



URTICARIA IN THE ADULT. 119 

marked, for the accompanying oedema rapidly appears and rapidly 
disappears. 

In some cases, in elderly people, who are apparently in good 
health, urticaria may assume the characters of evanida, perstans, 
and tnberosa together. I have seen several of these cases ; the 
only likely cause appeared to be disordered digestion, with flatu- 
lence, pain after food, &c. In these cases the tongue was sud- 
denly swollen so as to almost fill the mouth, the eye was closed, 
the face puffed-out on one side, the scrotum and penis became 
enormously cedematous, and tuberose patches of urticaria showed 
themselves about the arms or the legs. Such a case was lately 
under my care. It seemed to me that bottled beer was the 
exciting cause. But finally, apoplexy supervened, and carried off 
the patient. 

It occasionally happens that in the formation of wheals, instead 
of serum being poured out, a certain amount of haemorrhage takes 
place. This effusion of blood in connexion with the escape of 
serosity from the vessels is not confined to urticaria, but may take 
place under certain circumstances in connexion with almost every 
skin affection which is hypersemic and inflammatory — ex., pemphi- 
gus, herpes, &c. When the effusion is conjoined with the develop- 
ment of wheals, the blood generally raises the cuticle somewhat, and 
produces what is called purpura urticans. The cuticle sometimes 
bursts, and exposes a reddened surface that does not heal, and 
whence a certain amount of bloody fluid may ooze for a while. 
The name of urticaria hcemorrhagica has been given to this latter 
disease,* and it includes the so-called purpura urticans. The 
haemorrhage, however, is a mere epiphenomenon, though it indi- 
cates a purpuric tendency. These little hemorrhagic wheals are 
sometimes seen about the neck and face of nervous women and 
elderly men out of health. I have noticed in one case a large blotch 
about the knee of the same character. At first the spot itched, 
then a wheal appeared, and slight escape of blood into the epi- 
dermis occurred. 

Pathology. — It is very difficult to explain the exact agency by 
which wheals are (see Elementary Lesions, chap, iii.) produced. 
It is clear that the nervous system plays a very important part, 
and particularly the vaso-motor nerves. I cannot think that mere 
sudden dilatation alone of the vessels will account for the produc- 
tion of wheals. It seems to me that at the exact seat of the wheal 
there is sudden dilatation, probably succeeding contraction of the 
arteries, but at the same time some of the capillaries in the imme- 
diate neighbourhood are in a state of spasm ; and it is the obstruc- 
tion to the exit of blood from the part — perhaps in part due to the 
contraction of the muscular fibres in the skin, conjoined with 
the free dilatation of vessels — that gives rise to the rapid outpouring 

* Jiitte, Zeitschrift fur Klin. Med., 1859. 



120 URTICARIA IN THE ADULT. 

of serosity which is sufficient to produce wheals. But then this 
leaves the real difficulty unexplained. Upon what does the highly 
sensitive state of the vessels depend? That they are hyper- 
sensitive is all that I can say. The peculiar susceptibility of the 
nerves of the skin in urticaria is well exemplified in the following 
case, related by Dr. Heusinger, of Marburg. It was that of a 
boy, aged sixteen, in whom, "when lines were traced on the skin, 
the course of the lines, in the space of half a minute, reddened ; 
and upon this reddened base there quickly rose up white ridges 
or wheals, so that in two or three minutes the lines of the writing 
stood up in strong relief, as exact in figure as if they were cut in 
marble by the most able sculptor. At the end of thirty or forty 
minutes the writing subsided and vanished completely, without 
leaving behind a trace of its presence. When the red lines ap- 
peared they were accompanied with an elevation of temperature 
sensible to the young man himself, and amounting to 1-J- to 2^- de- 
grees of Centigrade, and when pricked with a fine needle the 
wheals gave forth a minute drop of serum, as do the wheals of 
urticaria ; but however much or frequently the experiment was 
repeated, the boy felt no inconvenience. In explanation of the 
phenomenon, says Dr. Heusinger, it is obvious that the stimulus 
applied to the nerves of sensation was reflected upon the skin in 
the form of redness, heat, and swelling."* 

Now then what is the sequence and nature of the phenomena in 
such a case as the above? First, there is a morbidly sensitive 
skin ; irritation is then applied, and is followed by spasm of the 
muscular fibres of the skin, and also of the capillaries, with subse- 
quent dilatation of these vessels. Then follow hyperemia or redness, 
escape of serosity elevating the central part more than the outside 
of the lines, the whole constituting what is termed a "wheal." 
The tissues are passive. The disordered condition of the nerves of 
the skin is the basis of urticaria, and the disordered sensation, 
burning, tingling, &c, preceding eruption, itself dependent upon 
hyperemia acutely produced, indicate as much. 

Causes. — Supposing that there is a peculiarly sensitive condi- 
tion of the nerves of the skin in urticaria, it is easy to see that 
wheals may be evoked in many ways — (1) by local irritants ; (2) 
by the circulation of acrid or effete products in the blood — ex., uric 
acid, bile, &c, which, coming to the surface, become oxidized and 
more active, and (3) by reflex irritation. Under the first head, or 
local excitants, rank the acarus, fleas, bugs, mosquitoes, lice, 
flannel, the contact of numerous other irritants, such as " jelly- 
fish." Under the second head must be placed certain changes in 
the blood induced by gout, rheumatism, or disordered digestion, 

* The case is recorded in Virchow's Archiv fur Pathologische Anatomie und 
Physiologie und fur Klinische Medicin, June, 1867. 



UETICAKIA IN THE ADULT. 121 

the circulation of medicinal substances, such as valerian, copaiba ; 
and under the third, pulmonary, gastric, uterine, renal disorders, 
mental anxiety, and emotions of various kinds. In all these cases 
there is an influence that directly acts upon the disordered suscep- 
tibility of the cutaneous nerve fibres. In very many cases the 
urticaria is not due so much to the circulation of any irritating 
substance or product, as to the reflection of impressions made on 
the stomach by dietetic errors. I know of no problem more diffi- 
cult of solution than the determination of the immediate cause of 
the eruption in some cases of chronia urticaria. 

I have indicated a good many exciting causes. I think that 
very frequently it is a loaded gall-bladder, the contents of which 
do not find their way to the intestinal tract in the usual manner, 
but are absorbed and circulated in greater or less amount with the 
blood, finding their exit chiefly through the kidneys. I have fre- 
quently noticed that some subjects are greatly relieved, by a sharp 
attack of bilious vomiting, from urticaria that is both extensive and 
chronic, but the disease returns apparently with the non-excretion of 
bile, only to be relieved by another attack of " biliousness." Now 
I hope no reader will be seeking for a distended gall-bladder in 
every case of chronic urticaria. It needs much discrimination on 
the part of the practitioner to determine whether the exciting 
cause is a local irritation, impurified blood, the reflexion of gastric 
irritation, mental worry, &c. &c, and each individual case must 
be judged upon its own merits. I should mention that asthma has 
been observed to be associated with urticaria in a peculiar manner, 
and urticaria is sometimes periodic or intermittent, and this con- 
comitance lends much weight to the idea of its being essentially a 
neurotic disease. Dumontpallier records a case of intermittent 
urticaria, for example, in which the attacks appeared each night 
for six weeks. The parents were both asthmatic, the grandfather 
was asthmatic, the grandmother suffered from angina pectoris and 
rheumatism, the brothers were rheumatic, and four of the children 
suffered from intermittent diarrhoea, alternating more or less with 
actual urticaria. 

Prognosis.— There is no gravity attaching to urticaria. Acute 
attacks ab ingestis are of short duration. Chronic urticaria is 
abominably troublesome; the intermittent form is also very 
obstinate. 

Diag7iosis. — Urticaria ought not to be confounded with any 
other disease. The sudden appearance of eruption and its capri- 
cious character, the tingling sensation, the presence of wheals, 
gastric disturbance, and irritability of skin, are absolutely diag- 
nostic. I have seen it mistaken for scarlatina rash, but the error 
detected by irritating the skin, which causes the appearance of 
wheals. The evanescent character of the wheals distinguishes 
urticaria from the erythemata ; and in the instance of erythema 
papulatum, there are primary papules and no wheals ; the eruption 



122 URTICARIA IN THE ADULT. 

is of smaller size, feels hard and is persistent ; the disease has 
in fact nothing in common with urticaria. It is its peculiarly 
capricious character which distinguishes urticaria. If. tuberosa 
wants the regular and persistent course, the lividity, the soft feel, 
the oval shape of erythema nodosum. 

Treatment. — The treatment of urticaria is most unsatisfactorily 
laid down in books. A no less excellent authority than Neumann 
disposes of it in thoroughly German fashion in sixteen lines. 
Generally speaking the reader is told to " correct any digestive 
disorder, improve the general health, and use remedies to allay 
itching." The practitioner ma} 7 of course content himself with 
palliative measures, but he should seek to discover such as tend to 
bring about a radical cure of the disease. If the reader will refer 
to the section on causes, he will see that there are three sets of 
excitants of the actual rash of urticaria — local causes, reflected 
mischief, and disordered blood states. Now this implies that an 
important distinction is to be drawn between different cases of 
urticaria — between urticaria as the sole disease, and urticaria as 
complicating or a consequence of other diseases. Under the latter 
head are found cases of urticaria secondary to scabies, and phthi- 
riasis, uterine disease, &c, and naturally treatment should here 
be immediately directed to the cure of the primary disease, though 
it w T ill be necessary to take local measures for allaying the irrita- 
tion of the skin. I always ask myself in the first place when a 
case of urticaria comes before me, Is it secondary to some local 
irritation 1 Have I to deal with scabies, or pediculi, or bugs, as 
the real cause of mischief ? If not, then I proceed to determine 
whether there be stomach mischief (dietetic error) directly 
poisoning the blood, or if not, if there is mischief in any particular 
organ, reflected upon the skin % I of course deal now particularly 
with the cases falling under the two latter heads, and will indicate 
the general principles of treatment. The means for alleviating 
and removing urticaria are local and general. In no case must 
the practitioner a moment lose sight of the morbidly sensitive 
state of the skin as a thing to be dealt with by special remedies. 
These are to be employed for the purpose of allaying and also 
preventing further irritation. In all cases flannel should be 
removed from contact with the skin, the utmost cleanliness should 
be observed, no sudden change of temperature should be permitted 
to play upon the skin, either by way of exercise, draughts, or the 
like. Then the skin should be soothed by emollient and alkaline 
baths, anointing it if possible with oil. I always further seek 
to relieve the skin and to give it rest, by throwing more work on 
the kidneys, and by the exhibition of saline aperients. And I 
also prevent the circulation of effete products, urea, uric acid, 
and control all kinds of disorder which may be reflected on to the 
skin, and lastly, tone up and lull by anodynes the nerve paresis. 
These are the principles of treatment. I find urticaria one of the 



URTICARIA IN THE ADULT. 123 

most difficult and unsatisfactory of all diseases to cure. But the 
acute are more satisfactory to treat than the chronic cases. 

The following is a resume of what appears best to be done in the 
several varieties : — 

JJ. febrilis. — In simple cases one may prescribe saline aperients, 
and eifervescents with milk diet ; debar the patient the use of 
stimulants, and exhibit alkalies largely diluted ; at the same 
time alkaline baths, with half a pound of carbonate of soda in an 
ordinary hip bath, may be prescribed twice a day, together with 
lotions of bichloride of mercury and rose-water, or cyanide of 
potassium lotions. (See Formulse 40, 44 — 6, 49, 54 — 6, 57 — 62, 
117.) 

If the patient be gouty, colchicum should be given with salines ; 
when fever runs high, I have usually given acetate of potash, 
with tincture of digitalis, and even potassio-tartrate of antimony. 

In JJ. ah ingestis, or urticaria caused by dietetic errors, it is 
important to administer at the outset an emetic (zinc or ipeca- 
cuanha), and to follow this by a saline purge, and subsequently a 
mixture of carbonate of ammonia, prussic acid, and infusion of 
cascarilla. 

The treatment of chronic urticaria is most tiresome and difficult. 
One has to analyse carefully every function of the patient, and it 
requires no little patience to arrive at a distinct conviction that 
what we are doing is a reasonable plan of treatment. If there be 
mental disturbance, change of scene does good. Pyrosis, atonic 
dyspepsia, deficiency of bile, inaction of the liver, non -excretion of 
urea, uterine disorder, must be treated upon general principles. 
Generally speaking, it is possible to discover some one thing which 
taken internally evokes the urti cation : it may be beer, or condi- 
ments of some kind. Where it appears that the functions of the 
body generally are properly performed, bromide of ammonium, or 
if the disease be periodic, quinine is useful. Aconite is another 
remedy, and arsenic is much vaunted ; I do not know that the 
latter has done much good in my hands. 

But in addition to the detection of particular causes of blood 
impurification, or of mischief in kidney reflected upon the skin, 
the general state of the patient deserves close attention. Many 
have been much depressed in mind. In others the general health 
has become disordered by want of rest, by dyspepsia of long 
continuance, or by residence In damp, ill-ventilated dwellings. 
Others are ansemiated, and so on. It is the duty of the physi- 
cian to deal wisely with such cases, and oftentimes to alter the 
whole habits of the individual, with a view to restoring the 
tone which he has lost. In certain cases, change of air, cold 
bathing, iron, and strychnine may be necessary. I have had 
not a few American clients of late suffering from urticaria, 
in whom the continuance of the disease was clearly due to the 
practice of " bolting " their meals. The food was never pro- 



124 URTICARIA IN CHILDREN. 

perly masticated, and consequently not properly digested, at the 
same time that the urine was loaded with urates, and to an 
extent that surprised me. More careful and deliberate mastica- 
tion, the avoidance of unwholesome dishes, and the use of the 
Turkish bath, with alkaline waters (Vals), happily seemed to act 
like magic in these cases, and prepared the way for cod-liver oil, 
steel, and quinine to fully consolidate the cure. In fact, given the 
sensitive state of the skin in urticaria, hyperemia may be excited 
by a multitude of internal and external influences, connected 
in the former case with the most different states of general health 
and of functional derangements of organs, and it is the duty of the 
dermatologist to define and to defeat the influence of the parti- 
cular excitant of the eruption in individual cases. The dietary of 
urticaria is a highly important matter. All rich, stimulating food 
should be avoided, together with sugar, salt meat, seasoned dishes, 
and beer and wines, if they the least heat the patients. But I 
have a word or two more to say with reference to the local 
treatment of these cases of chronic urticaria. The local treat- 
ment can but be palliative. For my own part I regard a free 
action of the skin, as a whole, to be great gain and aid to 
cure in these cases, inasmuch as it necessarily relieves the skin of 
much fluid, and so diminishes the chances of hypersemia, &c. But 
in the acute cases of urticaria the circulation is so active in the 
skin sometimes that any determination to it of blood specially 
brought about, is apt to make matters worse, and especially if per- 
spiration fail to be induced. In chronic cases the matter is different 
somewhat, and I use vapor baths freely in chronic urticaria 
with the greatest benefit, taking care to apply some soothing 
application to the skin (such as oil or a calamine lotion) on the 
patient coming out of the bath. The bath may be taken three or 
four or more times a week. 

B. URTICARIA IN CHILDREN, INCLUDING THE SO-CALLED 
LICHEN URTICATUS. 

The clinical features presented by urticaria as it occurs in chil- 
dren are somewhat different from those observed in the adult, and 
for convenience sake I have thought it wise to deal with the matter 
in a separate section. In the first place the " wheals or pomphi " 
which characterize urticaria are not developed in the skin of the 
young to so great an extent as in the adult, and they are 
generally succeeded by the formation of papules in the seat of the 
wheals. There is sometimes more than mere serous effusion as the 
result of the local hypersemia. The wheals are primary and the 
papules secondary. Hence the term urticaria papulosa not inaptly 
describes the urticaria in children. But inasmuch as itchy papules 
are developed in connexion with the urticaria of children — hence 
the term lichen urticatus, which I decline to use — and these papules 



URTICARIA m CHILDREN. 125 

are scratched and altered in aspect, so as to become "pruri- 
ginous," as it is termed (that is to say, the apices are marked by 
dark specks, which are small clots produced by the drying of the 
blood effused after scratching) urticaria in them possesses features 
not usually noticed in the adult. In the adult wheals rapidly 
come and go, and there is no continuous scratching of one 
part inducing excoriations and the like : but in the child persistent 
papules are formed, and these are changed by the continual 
scratching practised. Many of the subjects in whom these 
papules are formed are badly hygiened and badly nourished, and 
consequently ecthymatous pustules show themselves, whilst much 
pigmentary staining is also seen if the disease lasts some time. 
From what I have said it will be evident that urticaria in chil- 
dren is peculiar in that it is accompanied by the development 
of papules that become pruriginous in chronic cases and in 
badly nourished subjects. And it is very important to remem- 
ber that the longer the disease lasts, the more likelihood is 
there that the erythematous will give place to the pruriginous phase 
of the disease. In other words, on tracing out the history of 
cases of chronic "lichen urticatus," which consist simply of 
pruriginous papules with intense itching, it will be found that 
originally they presented the features of ordinary urticaria, with 
simple papules. This, then, is my second point — that the features 
of urticaria in children differ according to the age of the disease. 
There is a third point of great importance in regard to the 
urticaria of children, and that relates to the cause. In some cases 
it is only secondary to scabies, and in others it is, I feel con- 
vinced, excited by the attacks of bed-bugs, in children who are 
not properly cared for. ISTow it is, of course, most important to 
determine the existence of scabies, because the cure of the latter 
is all that is required to rid the patient of the urticaria ; but I shall 
refer again to this point under the head of diagnosis. In the fol- 
lowing remarks I, of course, deal with uncomplicated urticaria 
papulosa. 

Clinical Features. — If a child isbrought to the practitioner in the 
early stage of the urticaria or "lichen urticatus," the mother or 
attendant will say that the child is greatly tormented with an 
irritation ; it may be about the arms, ir chest, or face, or more or 
less generally over the body. The i Titation is greatest at night, 
and disturbs the child's rest. If the child be stripped one may 
find not much evidence of eruptior;, and the statement is made 
that it was very bad in the night or v ,he first thing in the morning. 
The disease in fact possesses one of the special characteristics of 
urticaria — capriciousness ; wheals or fugacious spots of erythema 
have formed but disappeared rapi Ily. In other cases scattered in 
greater or less amount over the body are red papulations, which 
are raised and feel hard in the centre, with a red halo, resembling 
in fact bug-bites. These ma v ^e interspersed with smallish 



126 URTICARIA IN CHILDREN. 

wheals. These papules become excoriated and " pruriginous." 
Hence the patient's surface may be studded over with the fresh 
papules, and also old pruriginous papules. The fugitive wheals 
and red papules appear chiefly at night, at which time itching is 
peculiarly distressing. When the disease has lasted some time, 
the skin, in consequence of the pi en tif illness of the papules, may 
feel quite rough, uneven, and harsh. But generally, save in 
chronic cases, there is a history of interminglage of wheals and 
small erythematous patches ; when the disease is chronic, the 
general characters are varied. The symptoms may get better and 
worse, the child having periodic outbursts of eruption ; but I have 
seen a condition of things developed out of the acute stage exactly 
resembling the so-called strophulus pruriginosis of Hardy (see 
Lichen). It occurred in badly nourished and more or less strumous 
individuals. In these cases the " wheals " were wanting, and the 
disease answered to the description of " prurigo," but it possessed 
an anterior history of urticaria. 

Cause. — Urticaria papulosa (lichen urticatus of children) occurs 
frequently, and in fact, as far as I know, almost entirely in hos- 
pital practice and amongst the lower order. I have seen it, of 
course, in the children of persons in good circumstances, but the 
fact remains that it is to be met with rarely in private and 
abundantly in hospital practice. Now I may mention, as throwing 
some light upon the nature of the disease, that some time since I 
made some observations upon the effect of an improvement in the 
personal hygiene of children upon the disease with which they 
are affected, with somewhat remarkable results. I admitted well- 
marked instances of the affection, both in its acute and chronic 
forms, into the children's ward of University College Hospital, 
and treated them with good diet and simple or alkaline baths. 
The cases, special attention being paid to cleanliness, got rapidly 
well. These same children were then sent home again, when the 
disease recurred in all its intensity, to disappear again at once on 
being taken into hospital, and to crop up once more on returning 
home, &c. The object of these experiments has been to show how 
large a part inactivity of the skin, uncleanliness, bad air, and the 
like, play in the intensification, if not the genesis of the disease, 
and in inducing that mal-nutrition which is so frequently evi- 
denced in it. But then many children suffering from the disease 
under notice are really well nourished, and have plenty of flesh on 
their bones, and in these the disease never becomes secondarily "pru- 
rigiuous." It does not appear that a badly nourished state of skin 
need be present ; but that mal-hygiene is an exciting cause, if not the 
sole producer of the disease, I am confident. But there are other 
conditions that influence chiefly to aggravate the disease. Defi- 
cient urinary excretion is one, scabies is another ; and I do verily 
believe the attack of bugs is another of very common occurrence 
indeed, but one that mothers as persistently deny as I affirm. 



FOLLICULAR HYPEREMIA. 127 

Disordered bowels is also a cause of aggravation of the disease. 
Occasionally one is puzzled at the obstinacy of the affection; 
fresh crops of wheals and fugacious papules spring up from time 
to time, and the disease is prolonged off and on for years. 

Treatment. — From what I have said as regards the cause, the 

feneral indications for treatment may be readily comprehended, 
n the first place, the general hygiene of the children must be 
carefully attended to. The most complete cleanliness must be 
observed. The child should be made to breathe pure and not 
vitiated air ; to have a thorough good bath and washing night and 
morning, and be given good and wholesome food ; all causes of 
local irritation (the attack of bugs, scabies, &c.) must be detected and 
removed ; the child should not wear flannel next the skin. Then it 
is advisable to soothe the skin with alkaline baths, followed up by 
application of some anodyne lotion. The action of the kidneys 
should be quickened, if need be, by bicarbonate of potash with 
or without the nitrate twice a day, the bowels being regulated, 
dyspeptic conditions removed, whilst the diet is to be such as sits 
lightly on the stomach, and is at the same time nutritious. The 
genral health requires attention. Whenever eethymatous or pruri- 
gineous features exhibit themselves, they should be regarded as indi- 
cations for the exhibition of quinine and steel, and cod-liver oil, or 
other appropriate tonics. Locally, it is well in acute stages to apply 
soothing remedies, such as emulsion of bitter almonds with a small 
amount of bichloride of mercury (gr. j — gr. vj to 3 vj) or warm lead 
lotion. For the chronic stages, I invariably use sulphuret of potas- 
sium baths in the proportion of 3" j to § ij to xxx gallons of water ; 
I am quite satisfied with the effect. I give the bath twice or thrice 
a week, using an oxide of zinc lotion, to which I occasionally add 
a little liq. carb. detergens ( 3 ij — 1 ss to § vj). 

FOLLICULAR HYPERZEMIA. 

It may seem somewhat strange that I should give a special 
description of hypersemia of the follicles of the skin. But I do so 
with a very practical object in view. I find that hypersemia of 
the follicles of the skin, referred to under Papulae (the elementary 
lesions) is often confounded with diseases which it complicates, 
•and it is important that this accident common to many dissimilar 
diseases and its true significance should be distinctly understood 
in relation especially to the matter of general diagnosis. 

Whenever the skin is much irritated, and particularly if scratch- 
ing is practised for the relief of itching, the follicles are apt to 
become congested. The result is that red hypersemic papules are 
formed by erection and turgescence of the upper part of the 
follicular walls. If the hypersemia persists long enough a certain 
amount of hypertrophous growth may take place as a consequence 
of the hypersemia, and solid papules may then form at the hair 
follicles which may from being scratched become covered at the 



128 PELLAGRA, OR ITALIAN LEPROSY. 

apex with scales of dried blood that has been effused from the 
excoriations; in fact, the papules become pruriginous. But this 
is only a secondary result, not a primary condition. Now it will 
be at once evident that this accident of follicular congestion must 
be found in a variety of diseases, and should be carefully dis- 
tinguished from primary mischief, though in itself it indicates an 
excessive irritation of the skin. 

This follicular hypersemia is accompanied by hyperemia of 
certain of the papillae, and papules are formed by hypergemic 
papillae, but the mass of the papules referred to are formed at the 
hair follicles. In eczema nothing is more common than to notice 
follicular congestion around the eczematous patch, particularly 
about the legs, and this condition is oftentimes most erroneously 
called eczema papillosum. The papule of eczema is formed in the 
papillary layer by the upraising of the epidermis by fluid, and it 
is potentially a vesicle. In urticaria, the scratching induces the 
same follicular hypersemia which is also seen in scabies, prurigo, 
and phthiriasis. I have seen it in chloasma, &c. If the hyper- 
semia is followed by deposit of lymph, a condition follows which 
is one of the things termed lichen pilaris (see chap, ix.) ; but if 
the reader understands that follicular congestion and its results may 
exist under any conditions in which hypersemia is present and 
scratching is practised, and that it is to be regarded as an index 
of an irritated state of skin, it is quite unimportant what 
name it be given. In fact, it is the sign of a " scratched skin," 
and should be always recognised as such. 

As the term "pruriginous" implies some relationship to 
prurigo, I much prefer the expression "pruritic" eruption for 
the state of things above described. 

PELLAGRA, OR ITALIAN LEPROSY. 

This disease is common in Tuscany, Lombardy, Yenice, Pied- 
mont, Parma, Modena, Ferrara, South of France, in some parts 
of Spain, and Corfu. It attacks the poorer population to the 
extent of four or five per cent, in the districts where it is most 
prevalent. Pellagra is a general disorder of the system ; the 
external manifestations are only a part of graver changes in the 
system at large ; but as the erythema which accompanies it is the 
pivot of interest for the dermatologist, I deal with the disease 
here. The symptoms of the disease may be arranged in three 
groups : — (1) Eruption of an erythematous type ; (2) Signs of 
diminished general power, and failure of nutrition ; (3) Cerebro- 
spinal symptoms. 

After exposure to the sun, the pellagrous subject feels in some 
part of his skin, upon which the sun has played, a tingling sensa- 
tion ; at the same time he becomes weak, feverish, the appetite is 
faulty, digestion is inactive, and diarrhoea troublesome, though 



129 

these latter-named symptoms perhaps mark rather the second 
stage of the disease. The cerebro-spinal symptoms, the result of 
inanition and the morbid blood-state that finally ensue, are head- 
ache, giddiness, impairment of special senses, cramps, convulsive 
movements, with loss of muscular power. The patient dreams, raid 
is despondent. 

The eruption makes its appearance on the exposed parts — e.g., 
the back of the hands, the outer part of the forearm, the fore- 
head and sides of the face, the upper part of the chest and the 
feet, and usually in the spring. It is supposed to be excited by 
the sun's rays. In the men who wear large straw hats the face is 
not so greatly affected, but the uncovered faces of the women 
suffer more. Red spots first appear, which quickly become dark 
and desquamate ; the surface beneath the scaly covering is red, 
thickened, rough, and fissured; there may be pain; and little 
bullae, it is said, may form, which die away and are replaced by 
bluish stains. In some cases the epidermis is shrivelled, and as 
if frozen or scaly. The eruption subsides in the winter. In the 
ensuing spring the whole thing is exaggerated, increasing from 
year to year ; each year the intermittence is marked by the in- 
creasing permanence of the discoloration. Lombroso notices the 
frequent occurrence of subcutaneous extravasation of blood in the 
form of petechise on the belly and chest. He notices also rigidity 
of the extensor muscles. In the latter stages these different 
symptoms intensify pari passu. The patient emaciates, losing as 
much as 25 per cent, of his physiological standard weight. Phthisis 
or anasarca may set in ; the skin becomes unhealthy, " callous ; " 
whilst delirium, suicidal mania, melancholy, epilepsy, idiocy, and 
hebetude, have each their victims. A typhoid condition is the 
final result, and death ends the scene. 

Dr. Lombroso depicts a peculiar form of pellagrous mania charac- 
terized by unusual precocity and activity of the intellectual 
functions in connexion with an arrest of the growth of the body, 
and the organs of generation especially. 

Pellagra has an average duration in fatal cases of five years. 
Sporadic cases may have occurred in England ; they take the 
form of an erythema about the back of the hands, with cerebro- 
spinal symptoms and debility. 

Etiology of the Disease. — Now, much has been done of late to 
place us in a position for forming a good estimate of the character 
of the disease. Its frequency is known : in 1830 statistical ob- 
servation showed that 20,000 out of a million and a half of the 
Italian population were affected ; this is somewhat about one- 
sixtieth of the people. It appears that in about 90 per cent, the 
pellagrous are poor peasants, in about seven per cent, artizans, 
and in three per cent, they follow other occupations. 

Opinion differs as to the influence of hereditary tendency, 
because the members of a family are generally placed under 
9 



130 PELLAGRA, OE ITALIAN LEPROSY. 

exactly similar circumstances — those very ones which probably 
engender the disease. Calderini noticed in 184 families com- 
prising 1319 members, inheriting predisposition, that 648 were 
diseased, 671 healthy, Pellagra is said to be the result of insanity ; 
this has been especially insisted upon by Billod. It appears that 
in Billod's asylum (St. Gemmes), patients are affected by pellagra, 
whil&t the inhabitants of the village near (1700 souls), and those 
of the entire district (22,000), are free from it. But it has to be 
shown that the inmates are not under the influence of exceptional 
conditions. It is a fact that the insane are affected. Dr. Landouzy 
determined this question by a special journey through Spain. 
He visited 44 asylums, in which were 22,873 lunatics, but of these 
only 73 were pellagrous. Pellagra, says Dr. Landouzy, in asy- 
lums, is only a matter "of general Irygiene and alimentation." 
During the five years ending 1861, only 310 cases of pellagrous 
patients have been admitted into the San Servolo at Venice — 82 
maniacal, two monomaniacal, 95 melancholic, and 130 demented. 
Comparing these figures with the statistical information already 
quoted, as to the frequency of the disease amongst the general 
population, it would seem that no excessive proportion of pellagrous 
persons exist amongst the insane who are attacked in common 
with those amongst whom they live ; and M. Brierre de Boismont* 
has recently given it as his opinion that the pellagra is not due to 
insanity. The converse proposition is however true. In about 
9 per cent, the pellagrous have some definite form of lunacy. In 
the Annates W Hygiene Publique et de Me decine Legale, Oct. 1866, 
is an article by M. Yernois, in which it is said that in the insane 
a cachexy is induced like the pellagrous, but the truly pellagrous 
cachexia only occurs in those who have eaten diseased maize, 
of which I shall now speak. 

The cause of the disease that finds most favour at the present 
time is the use of diseased (ergoted) maize, as food by the people. 
Now, it has been objected that pellagra is not known in parts 
where maize is largely used. For example, in Southern Italy, 
Sardinia, and Burgundy, the people are not pellagrous, though 
they use maize largely. This may be in part due to the use of a 
mixed diet. But it is also asserted that where pellagra is present 
the maize used is diseased, and where the disease is absent, the 
maize is sound and unaffected. So that those who dry their maize, 
and keep it dry, escape disease, whilst others even in the same 
district, who do not properly preserve maize, may be affected. This 
seems to have been made out. Prof. Lombrosof points out 
particularly that the pellagrous are the poor of the inhabitants of 
the country ; that pellagra is diffused in direct proportion to the 

* Aimales Medico-fsychologiques, Journal de F Alienation Mentale et de la Med. 
Legale des Alienes, Sept. , 1866. 

f Gioroale Italiano delle Malattie Veneree e delle Malattie della Pelle. Milano, 
1868, Gennaio e Febbraio. 



OR ITALIAN LEi-noSY. 131 

cultivation of maize, as especially exemplified in the case of Brescia 
and Cremona. Generally after wet and unhealthy seasons, the 
grain is liable to be attacked by a fungus, the Sporisorium maidis ; 
the maize, if it be not properly dried, undergoes change by the 
action of the parasite, and undoubtedly pellagra is most common 
after wet and unhealthy seasons. But it is still asserted that part 
of the cause is poverty, misery, bad hygiene, malarious atmosphere, 
bad water, and uncleanly habits — and these must deteriorate the 
general health — together with the exposure to the sun and the 
dry atmosphere of the summer time. Unhealthy seasons affect 
man as much as the vegetable world ; and the diseased maize, if it 
be not the efficient cause, is a certain index that the atmospheric 
and other external conditions that play upon man are none of the 
best. 

I doubt not, however, that pellagra is one of a class caused by 
eating diseased grain, including ergotism from rye, pellagra from 
maize, &c. 

The French Academy of Medicine awarded a prize in 1864 to M. 
Roussel* and an accessit to M. Costallat for certain theses which 
went to show that pellagra was unknown till the introduction of 
maize, and that the use of diseased maize was the real cause of 
pellagra. But a most interesting account of the disease, as it oc- 
curs at Corfu, has been recently given by Dr. Pretenderis Typaldos, 
the Professor of Medicine at the University of Athens, and as it 
confirms entirely the prevailing opinion as to the cause of pellagra, 
I cannot avoid summarizing it. Pellagra is said by Dr. Typaldos 
to be of recent origin in the island. In 1839 one case was seen 
by a practitioner; several in 1858; in 1859-60-61 48 cases 
were collected. The disease exists in 27 out of 117 villages, 
containing 15,158 inhabitants. The disease in one village is in the 
proportion of 1 to 1218 ; in another 19 to 480 of the population. 
Dr. Typaldos notices that the disease exists amongst the very 
poor, whose staple diet now is bread prepared from Indian corn, 
which is called " barbarella." The supply is prepared oftentimes 
for a week. " When fresh cooked it is soft and pleasant to the 
taste, but when dry, it is very heavy and indigestible. Of the 
persons whom Dr. Typaldos found to be labouring under pellagra, 
all without exception had lived upon this diet, either almost en- 
tirely or in chief part ; and he ascertained that the prevalence of 
the disease corresponded in the different villages to the extent with 
which maize constituted the food of the peasants. Thus, in some 
localities they entirely live upon or have in addition to maize, 
bread made with sorgho (holcus sorgum), rye, rice, or wheat, and 
he found that when such grains are used the people wholly escape 
or suffer only slightly from pellagra. The author further contends 
that it cannot be in consequence of the small proportion of the 

* Traite de la Pellagre et des pseudo Pellagres, par MM. Koussel, Paris, 1866. 



132 PELLAGRA, OR ITALIAN LEPROSY. 

azotized elements in Indian corn that the grain is injurious, for it 
has been shown that when rye, rice, or sorgho are used, the popula- 
tion do not suffer from pellagra, though those grains are still more 
deficient in azote than maize. He finally arrives at the conclusion, 
that the essential cause of the disease is the consumption of maize 
which has been imperfectly ripened or has undergone changes after 
being gathered, thus adopting the views of Ballardini, as advocated 
in the thesis of M. Roussel, and described by Dr. Peacock in a 
former article of this Review."* Dr. Typaldos explains the recent 
occurrence of pellagra in Corfu by the fact that within the last 
thirty years in Corfu the vine has been cultivated at the expense 
of the maize, which in consequence is largely imported from 
Albania, Romagna, and Naples. This is, however, as good as 
that grown in Corfu ; but grain is also obtained from the Danubian 
provinces, and as it has to undergo a long sea voyage it is con- 
siderably damaged and often mildewed. That from the Danube 
constitutes by far the largest part of the grain used in the island. 
Much of the grain sold is diseased, and those are specially pel- 
lagrous who use it. Dr. Typaldos finally remarks, that in 1857, a 
cold and wet season prevailed in Corfu, the grain was imperfectly 
ripened, and an epidemic of pellagra followed amongst those who 
consumed the unwholesome grain. 

Morbid Anatomy. — Our knowledge on this point is deficient. 
The brain is atrophied, the arachnoid opaque, whilst there are col- 
lections of yellow pigment masses on the capillary walls ; the spinal 
cord is congested, and serosity is effused around it ; the liver and 
kidneys are fatty, the lungs congested, and the tissues generally 
anaemic, and there is thinning of the mucous membrane of the in- 
testinal tract, and oftentimes ulceration. 

As to the nature of the disease, if altered maize be the cause, it 
is " an ergotism." I could not at one time shake off the impres- 
sion that malarial influences have something to do with the cause, 
but I admit I had no facts to go upon. 

Prognosis. — The rate of mortality varies much in different dis- 
tricts, as greatly as the frequency. Ballardini states that in the 
Milanese districts 78 per cent, get well, 13 are uncured, 9 have 
mental disease, 6 die from natural causes, and a few are suicides. 

Treatment. — This is plain ; avoidance of ergoted maize, change 
and variety of diet, the use of wine, and removal from pellagrous 
districts — Ballardini recommends the latter strongly — quinine and 
iron tonics ; avoidance of exposure to the sun, and an improved 
hygiene generally. The reader who is interested in the subject 
will find a good article in the Giomale Italiano delle Malattie 
Veneree e delle Malattie delta Pelle for April, 1870, by Prof. A. 
Michelacci, on the therapeutics and prophylaxis of the disease. 

♦Brit, and For. Med.-Chir. Review. 



TAR- ACNE. 133 

MEDICINAL BASHES, OR ERUPTIONS THE DIRECT RESULT OF THE 
ACTION OF DRUGS. 

The eruptions of the skin produced by the administration of 
medicinal substances, in many cases erythematous, are not a little 
important, and the dermatologist should be fully acquainted with 
them. I may refer to them here for convenience. 

ARSENIC. 

Arsenic. — I have never seen any eruption like an eczema induced 
by this drug. But I imagine that the drug may induce hyperemia 
of the skin. This hyperemia may be limited to the follicles, and 
in this case a papular rash appears about the face, arms, neck, and 
hands, or it may take the form of erythema and puffiness of the 
face and eyes, with much itching, or of erythema of the palms of 
the hands succeeded by induration. I have also seen pityriasis 
rubra develop when arsenic has been freely pushed for the 
cure of psoriasis. According to other writers it may excite herpes 
zoster, but I am by no means sure that the zoster is not a coinci- 
dence. When handled it produces ugly ulcerations, as in artificial- 
flower makers. It is contained in certain dyes, used for socks, 
&c, which excite when worn next to the skin very severe eczema in 
some cases, and especially in hot weather. 

IODINE. 

Iodine when given internally may excite an erythema of the 
face. 

IODIDE OF POTASSIUM. 

Iodide of Potassium in some cases is followed by the occurrence 
of petechias, in others by boils or slight acne. Of this I think 
there can be no doubt. 

IODIDE OF STARCH. 

Iodide of Starch. — When this has been very freely used to ex- 
tensive syphilitic sores I have seen it give rise from the absorption 
of iodine, I take it, to a smart attack of urticaria. I remember 
one case in particular, in which urticaria of the limbs and back 
was caused in this way. Though it is true the erythema was very 
persistent, yet wheals were present and capricious in their develop- 
ment and stay. 

TAR. 

Tar. — The development of an eruption on the skin, which takes 
the form of an eczema or an acne (tar-acne), as the consequence 
of the internal or too free external use of tar is accompanied 
mostly by symptoms of quick pulse, fulness in the head and 
stomach, high-coloured and scanty urine, which gives out the 
smell of tar on the addition of sulphuric acid. Rarely an eczema 



134 BROMIDE ERUPTION. 

may be acutely developed, but the tendency of tar, used for some 
time externally, is to give rise to an acne. At first the skin is 
dotted over with what are apparently comedones (acne punctata). 
These spots then inflame, and develop into regular acne spots. 
This form of disease is induced by the local action of tar vapour, 
an occurrence Neumann has noticed in tar manufactories. 

BROMIDE OF POTASSIUM. 

Bromide of Potassium when exhibited freely produces eruptive 
manifestations of different aspects, but all arising from stimulation 
of the sebaceons glands. The matter has been most carefully 
investigated by M. Voisin,* who speaks of five phases. I can 
confirm M. Voisin's observations. In the first place there is 
ordinary acne indurata, chiefly seen on the face, chest, and back, 
and sometimes accompanied by much erythema and some feverish- 
ness. Lymphatic and sanguineous persons are chiefly liable to be 
attacked. This is the commonest form of eruption : — " The 
second form of eruption given by Voisin as occurring six times in 
ninety-six epileptic patients who were under the bromide treat- 
ment, has, 'as far as his knowledge goes,' 'no analogy in the 
known forms of skin disease.' It appears in the form of oblong or 
roundish swellings on the lower extremities, of a rose or cherry-red 
colour, which then become yellowish, in consequence of certain 
millet-seed-like yellow prominences appearing upon them, which 
latter are aggregated acneiform pustules. These roundish swell- 
ings have a kind of depressed umbilicus in the centre ; their base 
is very hard ; they are unaccompanied either by swelling of the 
lymphatic glands or by feverish symptoms. It is seldom that 
more than two or three of these swellings are observed on a patient 
at one time. They are very painful on movement, only their 
centre is insensible (even to pricking, cold, &c). The pains are so 
severe that the patients are unable to move the legs. Voisin 
relates the cases of two women who, on account of this last 
symptom, could not leave their rooms for several months. These 
swellings disappear when the fluid they contain trickles out ; but 
this only occurs very slowly, the time varying from a month to a 
year ; then the swellings become covered with thick scabs, which 
remain until the tumefaction no longer exists; when they have 
disappeared, persistent yellow scaly patches remain. These 
swellings sometimes become developed very rapidly, in three or 
four days ; they occur more frequently in winter." 

JSTow I can explain this eruption. The truth is that the oblong 
swellings are produced by a crowding together of enlarged 
sebaceous glands (acne-spots) distended with sebum, which is of 
a more or less milky aspect. The " yellow-like prominences " de- 

* Societe de Medecine de Paris. M : moire sur les Eruptions Cutanees causees par 
l'usage interne du Bromide de Potassium. Voisin, Gazette des Uopitaux, 1868, p. 608. 



COPAIBA ERUPTION. 135 

scribed by Yoisin are composed of sebum confined beneath the 
epithelial layer, and distending the sebaceous duct and gland. 
In truth the disease consists in enlargement, in close aggregation, 
of the sebaceous glands in connexion with sebaceous flux, the 
sebum being retained in the distended follicle. It is almost of 
the nature of a crowding together of molluscous tumours. 

In the third form patches like those of erythema nodosum occur. 
It seems to be a kind of threatening acne with surrounding red- 
ness, of the nature almost of urticaria. 

In the fourth form furunculi and ecthymatous pustules are 
present. 

In the fifth, observed in one case only according to Yoisin, the 
eruption may be an eczema, in conjunction with pityriasis of the 
scalp ; but I suspect this is merely seborrhoea (sebaceous flux), but 
without retention of the sebum in the follicles. 

BELLADONNA. 

Belladonna produces a rash of rosy hue, fever, and a dry throat, 
together with dilated pupils — whatever may "be said to the con- 
trary. Dr. Fuller has denied this, but I cannot but think, espe- 
cially having regard to the large doses he has given without effect, 
that his extract has been inert. I am confirmed in my opinion by 
several communications from eminent physicians. 

HYOSCYAMUS. 

Hyoscyamus. — Dr. Robert Craik* describes a case in which a 
red rash like scarlatinal eruption followed the eating of " herbs " in 
a child, which herbs turned out to be the leaves of the hyoscyamus. 
I have no knowledge of any similar occurrence. 

COPAIBA. 

Copaiba. — I have seen a good many cases of copaiba eruption, 
which varies in aspect in different cases. Judd in his work 
described it as a rosy erythema, of " pumiceous " aspect, the 
skin looking as though it had been bitten by insects. As far as 
I have had opportunities of noticing the operation of copaiba on the 
skin in the production of actual eruption, it has seemed to me that 
the eruption is preceded and accompanied by the most intense 
itching, and the patient if at all feverish is not bodily ill. The 
eruption may be partial, limited to the two forearms, or the 
thighs, or the trunk, or more or less general. It is hypersemic, 
of a rosy hue ; usually it is like an urticaria without wheals, and 
it may be made up of circular bits. But if the hyperemia is 
followed by serous effusion, the eruption may be like an erythema 
papulatum, with large flattened rosy-coloured papules in some parts, 

* Montreal Medical Chronicle, Aug. 1858. 



136 SULPHUR BASH. 

and an erythema in others. I have seen one part of the rash like 
measles, and another like scarlatina. But this purely hyperaemie 
condition was an early one. Generally, however, there is a little 
serous effusion that elevates the hypersemic parts into urticaria- 
like blotches, or large flat papules interspersed over the reddened 
surface. But it is the intolerable itching, the similarity to urti- 
caria without wheals, and the pretty general distribution, with the 
related pyrexia, that is peculiar about the eruption, which occurs 
in those who have gonorrhoea, and are taking copaiba for its cure. 
Hardy* describes a case in which bullae developed out of the 
erythematous redness. There is a good illustration of this in the 
Dermatological Museum of the Royal College of Surgeons. 

The treatment of the disease consists in the abandonment of the 
copaiba, and in the prescription of alkaline baths, with oxide of 
zinc lotions and the free use of diuretics. 

ARNICA. 

Arnica may produce erythema and swelling of the part to which 
it is applied, or it may excite a real eczema. 

SULPHUR. 

Sulphur in some cases when used locally gives rise to a dry, 
dirty aspect of skin, occasionally to abortive formation of vesicles, 
or rarely an artificial eczema, with subsequent pityriasis, accom- 
panied by much itching. These induced states are often mistaken 
for the continuance or increase of the original disease against 
which the drug has been prescribed, mostly scabies, and it demands 
the most soothing treatment. A recent case I saw was that of a 
gentleman who had scabies ; he had been ordered a series of 
sulphur baths, which set up an artificial eczema, with ecthyma 
from the scratching. This rapidly got well (sooner than usual in 
these cases, for the sulphur impregnates the system) by demulcent 
baths and soothing unguents. Sulphur baths should be used with 
gentleness, and I think the old-fashioned villanous compound 
sulphur ointment less vigorously than is customary, for I feel sure 
that it is often continued long after the original scabies is cured, 
and upon which the secondary effects, erroneously regarded as the 
thing to treat, depend. I have seen grievous errors committed 
from a want of attention to the facts I have pointed out. 

CROTON OIL. 

Croton Oil. — When croton oil is applied to the skin — ex., the 
epigastrium, it sometimes becomes absorbed, and induces consi- 
derable flushing of the face, and in other cases extensive erythema 
of the same part. This may be due at the same time to the 
patient touching the face with the hands, to which croton oil 
adheres, but it also results from the absorption of the oil. 

* Pemphigus Aigu Consecutif a 1' Administration du Copahu. Hardy, Gaz. des 
Hopitaux, 1839, xxxvii. p. 141. 



CHAPTER IX. 

PLASTIC OR PAPULAR INFLAMMATIONS. 
GENERAL REMARKS. 

I use the term plastic inflammation to signify, in contradistinction 
to catarrhal inflammation, a morbid condition characterized 
by the deposit of lymph and probably the formation of a certain 
amount of new tissue, but without any serous effusion or pus pro- 
duction or implication of the subcutaneous tissue. This form of 
inflammation, in fact, to use clinical terms, shows itself by the 
formation of solid fleshy papules as primary phenomena; hence 
the term " papular inflammation." 

Now Willan included under the term papulae, three diseases — 
viz., lichen, strophulus, ana prurigo. His strophulus is a mixed 
affair, as I shall show further on in this chapter, and does not rank 
here. His lichen I retain. It is accompanied by dryness, and 
more or less roughness and general thickening of the skin, in 
addition to the formation of papules. It never has any " dis- 
charge " about it, and is caused by the effusion of coagulable 
lymph into the papillary layer of the skin. But under the term 
lichen, moderns include two new diseases, lichen planus (Wilson), 
the same disease as the lichen ruber of Hebra, and lichen scrofu- 
losorum (Hebra). Willan's prurigo included phthiriasis, or the 
disease due to the presence of the pediculi vestimentorum, in addi- 
tion to what I regard as true prurigo — viz., a disease in which fleshy 
papules accompanied by a general state of mal-nutrition, and severe 
and often intolerable itching, occur as the essential disease. 

Plastic inflammation then, in my opinion, includes two diseases, 
lichen and prurigo. It has been held that prurigo should be 
ranged with neurotic disease together with urticaria, herpes, and 
other maladies ; but though the nerves in prurigo play a very 
prominent part, it is uncertain what part at present, whilst recent 
pathological researches show that prurigo is essentially charac- 
terized as regards its morbid anatomy by chronic inflammatory 
changes. I therefore place prurigo in its present position ten- 
tatively. 

If the reader will compare the following descriptions with that 
found in books, he will find that I have simplified matters con- 
siderably by reducing the varieties of the diseases referred to. 



138 LICHEN SIMPLEX. 



LICHEK 



General Features. — This disease is essentially chronic and non- 
contagious, characterized by the appearance of little papules, about 
the size of millet-seeds, slightly red, or of the same colour as that 
of the skin, at first distinct from, though close to, each other, and 
being in some cases subsequently closely grouped together. The 
former distribution is often seen on the inner, the latter on the 
outer aspect of the limbs ; the papules feel hard and cannot be 
removed by pressure ; if they are scratched, in some varieties, a 
little clear fluid may ooze out. The skin generally is dry and 
thickened; there is considerable itching or burning. Once formed, 
the papules undergo little change until their disappearance ; but 
then scales form upon them, and these are dry, very fine, and 
greyish. The disease has a great tendency to recur, to chronicity, 
to be complicated by other forms of disease, and to spread from 
one region to another. It may be acute or chronic. The seat 
of the papules may be limited, or absolutely general. 

There are three chief forms of lichen : — ■ 

They are — (A) lichen simplex. 

(B) lichen planus, or lichen ruber (Hebra). 

(C) lichen scrofulosorum. 

These must be considered separately and in detail. 

A. LICHEN SIMPLEX. 

Now there are some who do not introduce this variety into their 
systems, believing that the disease which Willan described as 
lichen simplex is nothing more than a stage of eczema. With this 
view. I do not agree, because it is clinically untrue — at least so far 
as English practice is concerned. In the first place, Willan's lichen 
is quite distinct from the two varieties, lichen planus and scrofu- 
losorum. Further, Willan's lichen included certain diseases which 
have no relation to lichen ; but that there is a disease which 
answers to his description of lichen simplex, I am quite sure. No 
doubt the idea that eczema and lichen are the same arises from 
the fact that the papulation of eczema has been confounded with 
Willan's lichen simplex. But I will proceed to describe what I 
understand by lichen simplex, and point out afterwards where 
certain of the items which make up Willan's lichen should be placed. 

Lichen simplex includes as its sub-varieties, L. circumscriptum, 
L. agrius, and L. pilaris. 

Lichen simplex itself is often seen in the summer, sometimes re- 
curring in the same person several times ; the papules are flesh- 
coloured, red, smallish, sometimes very minute, and more or less 
pointed, lasting a week or so, and followed up by the development 
of others ; the papules are usually seen on the back of the hand, 
the outer aspect of the forearm, the neck, and the thighs. They 
are accompanied by a good deal of itching. The papules disappear 



LICHEN SIMPLEX. 139 

by resorption, and never become vesicles or pustules. This lichen 
may last for weeks and months. The disappearance of the papules 
gives rise to a little desquamation. The skin generally is dry and 
thickened. The disease is rare. L. circumscriptus is the name given 
to the disease when the papules are collected together into little 
round or roundish elevated patches; the border of the diseased 
patches in such cases is well denned and papular, the surface 
elevated, rough and dry to the feel ; its area increases by circum- 
ferential enlargement, and its centre presently clears somewhat ; 
there are generally several circles, and their most usual situation 
is the back of the forearm or the hip ; at other times the back of 
the hand or calf may be affected, or the inside of the thigh. The 
patches after a while get more or less scaly, or inflamed and cracked, 
simulating eczema, but never actually discharging ; or in conse- 
quence of the centre healing, assume a circinate form ; but the 
history, absence of moisture, and the dry red roughened base, are 
distinctive. When several patches run together and form bands as 
it were, the disease is named lichen gyratus (Biett) : this is nothing 
more than the coalescence of several circles of lichen circum- 
scriptus, and it is a fanciful designation. Lichen agrius, or the in- 
flamed form of lichen, differs from the above in the presence of 
secretion, and hence approaches eczema ; but it is, as its name im- 
plies, an acute, inflamed lichen. The local manifestation consists 
of clustered or closely-packed red papulae, accompanied by intense 
itching and burning, causing the patient to scratch violently ; this 
in its turn sets up additional irritation, the torn and excoriated 
papulae are inflamed, and exude a thin fluid ; the whole patch 
thickens, fissures, and becomes covered over with thin scales, not 
the yellow puriform scales of eczema. Lichen agrius may also 
arise, by inflammation of the chronic stage of any of the other 
forms of lichen, and not primarily as an acute form. The acute state 
lasts about ten or fifteen days, the chronic weeks or months ; this 
variety of lichen is observed about the back, neck, legs, arms, and 
shoulders ; it constitutes one aspect of grocers', bricklayers', and 
bakers' itch. Yesicles and pustules may however form ; and then 
there is an inflamed, raised, reddened, excoriated, discharging, 
fissured patch, the seat of intense and often intolerable itching and 
burning, made worse by stimulation of all kinds, especially the 
warmth of bed. This is no doubt a mixture of eczema and lichen, 
and is rightly termed eczema lichenodes or lichen eczematodes. 
The disease either subsides or increases by the development of 
fresh crops of papulae. In true lichen agrius, the papules form 
the prominent feature, and are a primary phase, the eczematous 
aspect being engrafted upon the lichenous disease. 

Kow lichen simplex consists, in an increase of blood in the 
papillae, and some escape of coagulable fluid into the tissues, in its 
simpler form,, and that is all. The reader will not confound it 
with that condition of eczema in which papules are produced by 



140 LICHEN SIMPLEX. 

serous effusion uplifting the cuticle, this being followed by the 
production of pus, &c. Nor is it the same as follicular congestion 
(see p. 127). But it is necessary that I should refer to some other 
conditions that are regarded as falling under the head of this 
lichen simplex. First must be mentioned, 

Lichen Pilaris. — Much dispute has arisen in regard to this variety. 
Occasionally one sees, either alone or in conjunction with ordinary 
lichen, or other disease where the skin is hyperaemie, little eleva- 
tions like papulae, which are however seated at the hair follicles; 
the hair in fact piercing the centre of the papule. A distinct 
lump is felt by the finger. There is no doubt but that hyperaemia 
of the follicular plexus is followed by fibrous deposit outside the 
follicle, forming a papule. It is more than hyperaemia alone. 
There is no reason why in ordinary lichen this should not happen, 
in the same way that hyperaemia and enlargement of the follicles 
are seen as an accident and accompaniment of other diseases. 
When the follicular hyperaemia goes beyond mere hyperaemia, as 
it were, and there is inflammatory deposit, then solid papules are 
formed at the hair follicles and constitute lichen pilaris. In- 
deed any irritation may induce this "lichen pilaris," and it is 
sometimes seen in chronic scabies. Lichen pilaris then is " fibrous 
inflammation" seated at the upper part of the hair follicles, the 
effusion of plastic lymph taking place around the follicular walls, 
and producing, according to its degree, more or less well-marked 
and distinct papulation, each elevation being perforated by a hair. 
It must not be confounded with pityriasis pilaris, which is merely 
a desquamation of cuticular cells into, and distending, the hair 
follicles, preventing the formation of the hair, and producing a 
blocking-up of the follicles, the collected cells forming " a knot" 
in the upper part of each follicle, a state of things that may occur 
after pityriasis rubra (see chap, xiii.), or as the result of an inactive 
state of skin, especially about the thighs, and which latter only 
needs the free use of soap and water for its removal. Lichen 
pilaris in the simple form above described must not be confounded 
with lichen planus, in which solid papules are formed at the hair 
follicles, for in this latter case the papules are seated at the 
deepest part, and are accompanied by the formation of new tissue, 
by hypertrophy of the cell elements of root sheaths, the disease 
having a peculiar history and course of its own.' 

Lichen tropicus is a disorder of the perspiratory follicles, and 
will be described in dealing with the diseases of these parts. 

Lichen urticatus has been described under the head of urticaria 
in children (see p. 124). The lichenous papules are secondary to 
development of urticarial patches. 

Lichen lividus is a purpura (see chapter xvii.). 

Lichen simplex, then, with its scattered papules, together with 
its sub-variety Lichen circumscriptus, in which the papules are 
crowded together so as to form patches; Lichen agrius, which 



LiuHmir simplex:. 141 

is an inflamed lichen; and Lichen pilaris, seated at the hair 
follicles — fall into a group under the head of simple or ordinary 
lichen. 

Pathology. — ISTow one of the broad distinctions between lichen 
and eczema is the entire absence of discharge in the former and 
v its presence in the latter, and it has seemed to me that the skins 
of lichenous patients, as I describe them, are not disposed to 
become eczematous. Instead of being pale, thin, and irritable, 
they are muddy-looking, tough, thickened, and not disposed to 
discharge. Very many different opinions have been held as to 
the anatomical seats of the papules. It has been said that the 
little solid elevations of the skin called papulae are seated at the 
sebaceous glands, but such are not lichenous papules. Others 
affirm that they are due to hypersemic follicles, with subsequent 
effusion, this is so in lichen pilaris ; others that they are enlarged 
papillae of the skin. I think they are produced by hyperemia 
and effusion of coagulable lymph in the papillary layer ; and this 
effusion is not limited, but is general, so that in well-marked 
cases of lichen, as I describe it, the whole integument as before 
remarked is dry, harsh, discoloured somewhat, tougher than 
usual to the feel, contrasting strongly with the thin, light, delicate 
skin of an eczematous subject. As far as microscopic examination 
has gone this has been shown to be true, for the vessels of the 
papillae are dilated and the papillary layer itself hypertrophied. 
In lichen the irritation set up induces turgescence of the sebaceous 
and other glands and follicular hyperaemia, especially in lymphatic 
subjects : but these phenomena are only accidental to true lichen. 

Prognosis is not grave. Lichen circumscriptus and lichen agrius 
are often very obstinate, so is so-called lichen pilaris and lichen 
occurring on the face. As a rule, the simple forms get well, 
with proper treatment, in two or three weeks. 

Causation is supposed primarily to be due to the existence of a 
peculiar (dartrous) diathesis, but of which I know and can com- 
prehend nothing. Lichen appears to be common in those of ner- 
vous temperament and in summer time. It attacks all ages, and 
is evoked by local and reflex irritation, by a deficiency of alkali 
in the system ; irregularities — mental, physical, alimentative, &c. ; 
hereditary tendency ; certain occupations — e.g., cooks, bakers, 
grocers, bricklayers, &c. ; by hot climates. Similarly in this as 
in other diseases — a predisposition to disease shows itself by tan- 
gible evidence whenever any determining cause unbalances the 
resistant power of the system. 

Diagnosis. — There are some difficulties here. The chief points 
to remember in regard to lichen are the dry and thickened state 
of the skin and the presence of papules, which are always to be 
found, if the disease is in patches, at the extending edge ; the 
hard feel of the papules, and their tingling or itchiness. Lichen 
simplex and scabies may be confounded. Lichen is uniform, 






142 LICHEN SIMPLEX. 



multiform. In scabies, besides papules there are vesicles, 
often pustules, and the papules are not so closely aggregated ; the 
eruption also is in the line of flexion, not, as in lichen, in that of 
extension — i.e., lichen is seen chiefly on the outer aspect of the 
arm ; it may occur on the back of the hands and fingers, but 
it is not interdigital. Lichen simplex never occurs in the feet ; It is 
common on the face ; scabies is not. In scabies too there is the 
characteristic vesicle and sillon, whilst the disease is contagious 
and easily removed by sulphur treatment. It is also seen in the 
seats of j)ressure, rarely above the level of the mamma, and not 
associated with the peculiar dry thickened state of skin, as is the 
true lichen simplex. 

Phtheiriasis may simulate lichen, but it is associated with an 
unhealthy, relaxed, muddy, dirty state of the skin, — flabby is the 
word ; the papules (which are pale) are fewer in number, and each is 
marked at its apex with a dark black speck (dried blood) effused as 
the result of scratching. The skin is not thickened and dry, as 
in lichen, nor is there any attempt at scaliness, as in lichen, nor 
aggregation of papules into patches or groups. Phtheiriasis is 
essentially a disease of advanced age. It occurs in the uncleanly, 
and there is often a peculiar urticated state of skin, seen very 
markedly on the back and chest, produced by an exaggeration of 
the spaces enclosed by the normal furrows. Phtheiriasis does 
not occur about the face ; the sensation is one of formication, and 
is altogether out of proportion to the local disease, whilst pediculi 
may frequently be detected in the folds of the linen. 

Lichen agrius resembles eczema, but the latter is moist and dis- 
charging, occurs in delicate and thin, not in harsh dry skins ; 
again, the history and edge of the patch in lichen point to the ex- 
istence of papules ; then the patch is much thicker and harsher 
than in eczema, and wants its thick yellow crusts : the latter in 
lichen are thin, pretty few, and " flimsy." 

Lichen circumscriptus, with its papules, ought not to be con- 
founded with vesicular or furfuraceous tinea circinata, in which a 
parasite is found ; nor with psoriasis, which is entirely devoid 
of discrete papulae, and presents peculiar white imbricated scales, 
and possesses as its selective seats the points of the elbows and 
knees. 

It is important to remember that scabies may be complicated with 
lichen, and the latter may be set up as the result of irritation in scabies. 
One sees this state of things very frequently in the hot season — 
the irritation of a few scabious spots bringing out a pretty 
general lichen. 

Treatment. — The early stages of lichen, when accompanied by 
febrile symptoms, may be treated upon general principles. Salines, 
aperients, tepid alkaline baths, to which may be added bran, gela- 
tine, size, and the like, are proper. In lichen agrius, poulticing, 
rest, and lead lotion, or such ointments as are given in Formulas 



LICHEN SIMPLEX. 14:3 

57, 59, 67. To allay itching at this stage, besides the baths, oint- 
ments of cyanide of potassium (54-55) may be used in the proportion 
of three or more grains to an ounce of lard.; oxide of zinc, borax, 
of each a drachm, camphor ten grains, and adeps one ounce ; or 
bichloride of mercury or borax lotion. Then, when the disease 
has passed the acute stage, the patient must be treated according 
to his constitutional bias. In a goodly number of cases it will be 
noted that the patient is overworked, worried, not taking sufficient 
food and rest, is annoyed by dyspepsia, or is looking thin and 
anxious. In such cases a change from any depressing overwork, 
the correction of acid or atonic dyspepsia, mild aperients, and a 
course of mineral acids and bitters, will speedily be attended with 
benefit. The local treatment consisting in the use of mild un- 
guents (ung. plumbi) or zinc and dilute nitric acid lotions. 

In other cases, where the urine is loaded, and the skin generally 
is discoloured and harsh, alkalies are of service, and may be given 
with ammonia and bitters, together with alkaline baths and borax 
lotions. In other cases it is apparently impossible to say that any- 
thing beyond general debility exists ; under such circumstances 
arsenic is to be employed. In lichen circumscriptus again, an 
alkaline course is beneficial, and if there be any tendency to 
rheumatism, iodide of potassium, with quinine, may be given in 
addition ; and in lichen agrius gouty tendencies must be met in 
the first instance by colchicum. In the former variety of lichen 
weak mercurial ointment, the citrine ointment diluted four or six 
times, or the ammonio-chloride (grs. v to § j) or acetate of lead, 
iodine, iodide of sulphur, or sulphur ointment, according to the 
induration and chronicity of the patch, and in the latter variety 
maceration with glycerine, borax 3 j to § j of adeps with glycerine, 
or ammonio-chloride of mercury ointments, and lastly, painting 
with a solution of nitrate of silver, or glyceral tannin, are of use. 

When the disease is very chronic, and there is much thickening 
of the skin in general, and in lichen pilaris, a course of bicyanide 
of hydrargyrum, in the same doses as the bichloride, with bark, 
will speedily cause resorption of the plastic material poured out 
into the derma ; and local stimulation of the skin with sulphur 
vapour baths may then be employed. But, indeed, no one plan 
can be laid down for lichen. Each patient must be treated ac- 
cording to his individual peculiarities — one man will need cod-liver 
oil, another steel, a third aperients, a fourth arsenic, a fifth colchi- 
cum, and so on ; but the tendency should be in the early stage 
to use alkalies, and in the later stages arsenic. The too free and 
early use of stimulants to the skin should be avoided — emollients 
and alkaline baths being most fitting for recent disease. In all 
cases stimulants are to be dispensed with entirely if possible, and 
the food is to be unstimulating. A very good form of local appli- 
cation for itching is half a drachm of dilute hydrocyanic acid, 
Brandish's solution of potash half a drachm or a drachm, and six 



144 LICHEN PLAJNUS. 

ounces of rose water. (See Formulae, Nos. 40, 41, 46, 49, 57, 61, 
68, 70, 89, 131, 151, 153, 162, 173, 180, &c.) 

B. LICHEN PLANUS. 

This disease, lichen planus, which includes the lichen ruber of 
Plebra, is an exceedingly well marked form of cutaneous disease, 
and I have a good deal of special information to give on the 
subject ; as by good fortune, since the last edition of this work, I 
have had no less than three cases of the veritable lichen ruber of 
Hebra under my care, if not four, and a goodly number of cases of 
lichen planus, so admirably described by Mr. Erasmus Wilson. 

Lichen planus may occur in two forms — the limited, and the 
general. The former answers to the lichen planus of Wilson, the 
latter to the lichen ruber of Hebra. I prefer the former term 
because it directs special attention to a peculiar physical charac- 
teristic of the papulae found in the disease, and shall use it as the 
best designation for the disease as a whole. I propose to consider 
the disease as it occurs in a localized form, with the papules discrete, 
or in a general form, in which the disease shows a special tendency 
to invade the whole body by the formation of large patches. The 
former 1 have noticed to be slowly developed, the latter rapidly 
or acutely so. The latter is rare in England, the other fairly 
common. 

Now for the guidance of the reader I may say that the papules 
are formed by changes taking place not at the superficial part, as 
in lichen pilaris, but the deeper parts of the follicle — viz., the 
papilla, and the root sheath. 

General Description of the Eruption. — The disease lichen planus, 
as generally seen, is characterized by the development of papules 
of very peculiar characters ; as regards colour, shape, structure, 
aggregation, behaviour, seat, chronicity, and accompanying phe- 
nomena. As regards colour : They are " dull crimson red," suffused 
with a purplish tint : shape : they are always flattened, smooth, 
shining, and horny-looking at their apices, one to three lines in 
diameter, and have an angular base, whilst in their centre, which 
is sometimes depressed or umbilicated, is to be seen the opening 
of the hair follicle. There are no scales seated upon these papules 
except when they are packed closely together so as to form patches. 
Structure : These papules are formed not by the filling-up of 
the follicle, but evidently by the formation of new tissue around 
and about the follicle at its deepest part. If a hair be extracted, 
it may be possible to detect adherent to it the root sheath much 
hypertrophied. Aggregation : the discrete form is always present at 
the outset, but this always exhibits a tendency to become the 
aggregated, so as to form patches, but not by the peripheral en- 
largement of the existing papules, but the springing-up of new 
between the old ones. When patches are formed, the parts 



LICHEN PLANUS. 145 

become more and more infiltrated after a while, whilst the indivi- 
duality of the separate papules is lost, more or less, save at the ex- 
tending edge of disease where characteristic papules are always to 
be seen. Behaviour. — The papules never assume the aspect of any 
other of the elementary forms of eruption — i. e., they never become 
vesicles or pustules. They are in fact primary formations and pre- 
serve the characters of papules till they begin to subside and dis- 
appear. Seat of Eruption. — The most characteristic seats are the 
front of the forearms and wrists, the flank, the lower part of the belly, 
the hips, and over the vastus interims about the knee. Chronicity. — 
The disease is very chronic, it is often local, and always more or 
less symmetrical. Concomitants. — There is often a deep red hue in 
the seats of eruption, with burning and intense pruritus. I have 
usually notieed a flushing or bronzing of the face : occasionally 
brittleness of the nails : at times great debility, and in some cases 
marked digestive troubles. When the papules disappear they 
leave stains, and the patches diminish by absorption of the new 
tissue which forms the papulae, and then in some cases in place of 
the elevations little pits remain. The material forming the papulae 
has, as it were, stretched the natural integuments, and on that 
account perhaps the pitting is more obvious. 

The more Localized Form. — Lichen planus, as generally seen, may 
consist of two or three collections of papules, tending to the 
formation of patches, in a single region of the body, or in two or 
three places at the same time — the thigh, the front of the forearm, 
and the flank, for instance ; or it may consist in scattered papules ; 
or it may be general, as I shall presently notice. In one of my 
cases the woman has lost all signs of eruption, but her skin is 
stained something like that of a patient with Addison's disease, and 
she is gradually sinking from intense nervous debility ; but this 
is unusual. 

The Exaggerated, or more General Form. — The more general 
and severe form of the disease as described by Hebra under the 
term L. ruber, and as I have seen it in England, commences 
by an eruption of miliary papules, which are at first distinct one 
from the other, but soon coalesce so as to form patches by the 
development of new between old papules, the patches being covered 
by small, thin, not very adherent scales. When a large extent of 
surface is attacked, the integument, in an advanced stage of the 
disease, u is universally reddened, covered by numerous thin 
scales, and so infiltrated that when a fold of skin is taken up it 
is found to have more than twice its normal thickness. But on 
close examination the papules are detected at least at the edges 
of the patches. The movements of the part may become affected, 
and the hands be stiffened ; flexion and extension of the fingers 
and toes be difficult ; the skin of the palms of the hands and 
soles of the feet be hardened ; and rhagades appear. The nails 
may become thickened, opaque, rough, and brittle, or thinned and 
10 



146 LICHEN PLANUS. 

platy ; but I have noticed this in the discrete variety when 
there was very little eruption. The hair of the head and axillae 
is unaffected. Hebra says, in the later stages troublesome itching 
occurs, but not so great as to induce scratching and resulting 
excoriations. My experience is that this prevails in almost all 
cases throughout. Marasmus and death may finally set in. 

In the three well-marked cases of the kind which I have had 
(see Brit. Med. Journ., April 13, 1871, Clin. Soc. Trans., 1872) 
there was no distortion of the hand and fingers, and no marasmus, 
but the general appearances described by Hebra as existing in 
the skin were well marked. 

In one case I observed a good deal of hypersemia of the sur- 
face generally, and the actual papules were preceded by red 
hypersemic puncta, seated at the hair follicles, this condition 
appearing to be the first and necessary stage to the actual pro- 
duction of solid papules. It may be as well to add, that the 
eruption in progress of cure, as far as I have seen, alters its 
features. The universal thickening breaks up into closely 
arranged patches — that is to say, limited areas covered by red 
distinct papules appear, the red papules after a while subsiding. 
When the disease has still further advanced towards cure the sur- 
face instead of being papular in aspect may present little pits in 
the sites of the former papules. 

Now, as I have hinted before in speaking of the division of the 
disease into localized and general, the latter has seemed to me 
to differ from the former in developing more acutely over the 
general surface, and there is a case under my care, in hospital, 
at the time I write, in which the whole body was attacked within 
a week on two. 

In both forms of the disease the general health is bad. 
Patients are very frequently dyspeptic, anaemic, or menorrhagic, 
and thoroughly debilitated. I have never seen them go from 
worse to worse. But great care is required to bring them back 
again into health. I have seen the disease lichen planus, at all 
ages from sixteen years upwards. The more severe form I have 
noticed only in women, who have been much depressed in 
various ways. The disease in all its forms is most rebellious to 
treatment. 

Summary. — To sum up then in regard to naked-eye appear- 
ances, I may observe that lichen planus is characterized by the 
presence of very peculiar papules, which papules tend to crowd 
together into patches. 

The disease may consist in the development of a few papules in 
a solitary region, or in a mixture of distinct papules and separate 
patches. In some cases however nearly the whole surface may 
be involved and then the crowding together of papules into 
patches is so great that the whole integument of the affected 
part is reddened and thickened so that the papular aspect is lost, 



LICHEN PLANUS. 



147 



except at the edge of patches or outlying parts. The surface is 
then covered over by thin, fine, and slightly adherent scales. In 
Hebra's experience the latter phase is a serious matter involving 
marasmus and death. 

Pathology. — The remarks I shall now make will, I hope, with 
the aid of the description just given of the external aspect and 
course of the disease, enable the reader to understand lichen planus 
without difficulty. 

First of all as regards the actual changes in the skin. These 
differ as might be anticipated according as the disease is in its 
early or its later stages. 



Fig. 10. 



The first condition that 
seems to me to be present is 
hyperemia of the papilla and 
the follicular wall about it, 
with hypertrophy of the root 
sheath at the lower part of 
the follicle. I have managed 
to get away with the hair a 
portion of the attached root 
sheath, from an isolated but 
well-marked papule, and 
found exactly those appear- 
ances which are given in the 
accompanying illustration of 
Neumann (fig. 10). 

It will be seen that there 
are knob-like projections 
formed by outgrowths from 
the root sheath of the hair 
and these outgrowths are 
made up of cell-masses. In 
the more fully developed 
disease other changes may 
be observed, in the root 
sheath at its upper part, and 
also in the general area of 
the corium. 

The upper portion of the 
root sheath of the hair be- 
comes in some cases greatly 
elaborated and hypertro- 
phied, producing an appearance represented in Hg. 11, which I 
sketched from a, specimen taken from one of my cases. Hebra has 
remarked that the root sheath of the hair is enlarged, being 
"pointed below, expanding towards the mouth of the sac, and 
looking as if it were made up of hollow cones, loosely included in 
one another, and having the hair in the middle." In fig. 11 the 




(After Neumann.) 

Knob-like projections about the root of the hair 
formed by cell-growths. 



148 



LICHEN PLANTS. 



hair is seen to be embedded in the enormously hypertrophied root 
sheath, represented by the fibrous mass expanding from below 
upward. The hair itself was just visible to the naked eye in the 
centre of one of the lichenous papules, and I managed to get it 
away with the attached root sheath entire, at least at the upper 




part. I did not find any trace of hyperplasia about the root of 
the hair as represented in fig. 10 in this particular case. 

I spoke a moment since of changes in the cutis. As the result 
of the hyperemia in the disease, the epidermic layers, both horny 
and rete, are hypertrophied in long-standing cases. The papillae 



LICHEN PLANUS. 149 

are likewise enlarged and their connective tissue increased, their 
vessels are dilated, whilst a dilatation of capillaries and small vas- 
cular trunks is also seen in the corium. The vessels moreover are 
surrounded by cells, which are probably proliferated connective- 
tissue corpuscles. The sweat glands, according to Neumann, are 
healthy, but their ducts are funnel-shaped, having the large end 
above, and are filled with small, closely-packed cells. The seba- 
ceous glands seem after a while to be pressed upon and to dis- 
appear. The muscular fibres attached to the hair follicle are 
much hypertrophied. The hair itself ends below in the " brush- 
like" expansion, surrounded by the knob-like outgrowths before 
referred to (fig. 10). 

Taking into consideration the clinical history of the disease 
and the morbid changes actually discovered in it, it seems to me 
easy to give an explanation of the disease, and to determine the 
exact sequence of events. The disease commences primarily at 
the bottom of the hair follicle, with hyperemia of the papilla, and 
the formation of new tissue by proliferation of the cell elements 
of the root sheath : the hypertrophic or inflammatory infiltration 
in the papillary layer being a secondary matter. The reader, if 
he will glance over the particulars of the cases I have elsewhere 
recorded, will not fail to observe that careful observation detected 
red puncta seated at the hair follicles as the early stage, and of 
course these were more noticeable where the disease developed 
rapidly ; and these red puncta were seen to be followed by the forma- 
tion of actual papules, and so on. But then if I am required to give 
a reason for the limitation of the disease to the deep portions of the 
hair follicles, I can only point to the fact that it is so limited. 

The immediate cause of the hypersemia and cell changess eems 
to me to be disturbance of the action of the sympathetic (? trophic) 
upon the vessels of the papilla. This is part of a general disturbance 
which accounts for the suffusion of the face, the menorrhagia, 
the pyrosis, the cramps in different muscles, peculiar restlessness, 
special dryness of the mucous membranes, irritability of the heart, 
disorders of the special senses, some or all of which I have noticed 
in my three cases of general lichen planus, and many of which have 
been present in instances of the more localized form of disease. 

Diagnosis. — It is difficult to understand how the eruption of 
lichen planus can be confounded with any other disease, if atten- 
tion be paid to the dull red, flat, shining character of the papules, 
leaving behind on their disappearance melasmic staining. 

Treatment. — In lichen planus the practitioner has to deal with an 
idiopathic hyperemia of the deeper parts of the hair follicles and 
hypertrophous growth of the root sheath, followed secondarily by 
hypertrophy of the papillary layer of the skin, and in association 
with hypersemia and functional disturbance of important internal 
organs, and serious derangement of the general health. The 
remedies are both local and general. 



150 LICHEN PLANUS. 

As regards general remedies, there are four indications : the first 
is to improve the tone of the patient as regards his nervous system, 
by proper rest and quiet, by change of air and scene, and the avoi- 
dance of fatigue if necessary. The cure is not solely a matter of mere 
dosiug the patient. The general tonics appropriate to the disease are 
quinine, cod-liver oil, the mineral acids, and perchloride of iron. 

The second indication is to alleviate internal troubles — of stomach 
especially — and it is necessary to do this before beginning a tonic 
treatment. In one case I used assafceticla largely at the outset, 
because of the Irysterical tendency of the patient, who suffered 
from severe heart excitement, menorrhagia that weakened, and 
nervous dyspepsia that much depressed and troubled her ; and I did 
so with good effect. But I have noticed that in patients who are 
dyspeptic, the irritation of the skin is much aggravated by the 
ingestion of food, &c, and in these cases I have given alkalies 
with bitters largely and with good effect, subsequently using iron 
and oteher tonics. 

The third indication is to feed up the patient whenever there 
is evidence that his or her living has been bad or defective ; but in 
order to do this it is necessary that such conditions as dyspepsia, 
pyrosis, or the like, be first of all removed. 

The fourth indication is to attempt to diminish the hyperemia by 
astringents given internally — ex., the perchloride of iron. But this 
cannot be undertaken till special influences that intensify the 
irritation of the skin — ex., dyspepsia, &c, are properly negatived. 
I like the perchloride of iron in full doses in cases of lichen planus. 
With regard to arsenic I can only say that it has always made my 
cases worse. In some instances of lichen planus in the discrete 
form, where the papules have been particularly solid and there has 
been less hyperemia than usual and the patient was fairly strong, 
I have given alterative doses of mercurials with very great benefit 
indeed, in conjunction with cod-liver oil. 

But having said so much as to the general indications, I may be 
more precise on one special point. If the hypersemic feature of 
the disease be specially well marked, and the disease be general, I 
never hesitate to give diuretics freely, because I believe I relieve 
the skin greatly ; and so if there be very little hyperemia, compara- 
tively speaking, and more " deposit," so to speak, I would use 
mercurials or alkalies as the case may be, to quicken the absorp- 
tion of the new tissue composing the papules. 

Lastly, internal medicines are required to allay itching. I have 
tried a good many. Aconite, chloral hydrate, carbolic acid, and 
opiates are the best ; but these do not answer particularly well, 
and I think local measures are the best for the purpose. 

Local Measures are employed to allay irritation, to diminish 
hypersemia, and to stimulate the absorbents to get rid of the 
newly-formed tissue. I do not know that I can say that any one 
remedy will allay the itching in all cases. If the disease be acute 



MCHEN SCEOFULOSORUM. 151 

and pretty general, alkaline baths (bicarbonate of soda with bran), 
followed "by a bismuth lotion — ex., R. bismuthi trisnitratis 3 ij, 
P. zinc oxyd. 3 ij, tr. digitalis p ss, aquae ad J vj, may relieve. A 
lotion made of prepared calamine powder § ss, prussic acid 20 to 
30 drops, borax § j, and rose water § vj may be of use. In some 
cases dusting the surface over with oxide of zinc powder will 
benefit. But if the case be chronic, and more or less indolent, 
vapour baths, followed by the application of oil or the unguentum 
plumbi (Formula 121) spread on strips of linen will often benefit the 
patient. Iodoform ointment has relieved some patients greatly, 
but it is very unpleasant to use. The oil of cade in the proportion 
of 1 part to 4 of unguent gives relief in chronic cases. But my 
plan is to be very tenacious of using any stimulant when there is 
hypersemia, for this seems to be readily increased by irritants : 
to trust to a general improvement of the health for the cure : to 
allay by sedatives the distress of the immediate irritation : to give 
alterative doses of mercurials if there be much thickening and 
the patient is not depressed or debilitated, and finally to employ 
tar or vapour and sulphuret of potassium baths. I have seen 
cases relieved solely by alkaline baths and the application of milk. 
But all these cases of lichen planus will sorely try the patience of 
doctor and patient, and it is as well to announce to the patient 
in the first instance the probability that this will be the case. 

C. LICHEN SCROFULOSORUM. 

This disease occurs essentially in strumous subjects. It shows 
itself, according to Hebra, who first described it, in the form of 
little elevations about the size of millet-seeds, either pale, or 
yellowish, or a brownish-red colour. These papules never become 
vesicles; they are grouped together, sometimes in circles, some- 
times in segments of circles. The papules are seated at the hair 
follicles, and are by-and-by covered by thin scales; the patches 
itch slightly, but not so much as to be scratched, and hence they are 
not excoriated. 

The patches remain in one condition a long time, and undergo 
no changes but exfoliation and involution. The disease is 
limited to the trunk, the belly, the breast, and back, being rare 
on the extremities. Its course is very slow. Generally speaking 
many groups of papules develop at the same time. They soon 
reach the height of development, and then remain awhile in statu 
quo. In consequence of the absence of local symptoms, the disease 
exists unnoticed for some time. When at its acme, other symp- 
toms are observed : between the groups, and at the same time, on 
parts free from lichen — that is, on the extremities and face — more 
or less numerous isolated bluish-red elevations are developed; 
these are about the size of lentils, and look very much like com- 
mon acne; some of the papules are said to contain pus ; then by- 



152 LICHEN SCROFULOSOROI. 

and-by they wither and disappear, leaving dark pigmented orbi- 
form lentil-sized marks in some places, whilst in others fresh 
formations take place. The skin between the diseased patches 
is the seat of desquamation, the scales being pale and shining, 
wmilst the whole skin may assume a cachectic appearance. In 90 
per cent, the disease is observed in markedly scrofulous subjects, 

Fig. 12. 



1 vv 



V. 










Lichen (Figure after M. Kohn. Sitzuugsber. d. kais. Akad., 1868). a. 
Hair follicle, b. Hair. c. Root sheath of hair traversed by cells, d. Rete 
mucosum thickened, cells longitudinally displaced ; exudation cells be- 
tween them. e. Epidermic mass at aperture of follicle. /. Sebaceous gland. 
g. Cells around sebaceous gland and hair-follicle, h. Adjacent normal cel- 
lular tissue. i. blood-vessel. 

and particularly children, together with swelling of the submaxil- 
lary, cervical, and axillary glands, with caries and necrosis, or tabes 
mesenterica. In one case recorded by Neumann there was lung 
disease. Hebra has seen many cases, and all recovered. The 
disease is not phthisical pityriasis. Each knot or papular eleva- 
tion is seated at the orifice of a hair follicle, and is made up of 



STROPHULUS. 153 

epidermic scales and fatty matter, in the form of fatty nuclei 
within the cells. The disease is seen almost exclusively in males, 
between the ages of fifteen and twenty-five. It may occur in a 
child under seven years. It is an infinitely rare occurrence in this 
country. 

Pathology. — Some interesting studies of the morbid anatomy of 
this disease have been made by Kolin, of Vienna, who gives the 
accompanying representation (fig. 12) of what he found in it. 
He says that the essence of the disease consists in the presence 
of exudation cells in and around the hair follicles and the related 
sebaceous glands, and the papillae about the aperture of the fol- 
licles. These cells make their appearance in the first instance 
outside the vessels at the lower part or base of the hair follicle, 
and the fundus of the sebaceous glands ; but subsequently they 
are to be found within the sebaceous gland and the hair follicle 
itself, and to so great an extent as to separate the hair from its 
sheath, and to form a collection which takes the form of a plug 
in the orifice of the follicle — " the knots " before referred to. 
According to Kohn the papule is not due solely to distension 
of the follicle, but to the presence of cells about the follicle. How 
far the disease is primarily a choking-up of the follicles by des- 
quamated epidermis, followed by acne, the occurrence of which 
is favoured by the strumous diathesis of the patient, is an in- 
teresting question. The disease gets well under treatment, with 
atrophy of the hair and follicular walls, and a certain amount of 
cicatrization. 

The treatment of the disease is simple and effectual. It consists 
in the liberal exhibition of cod-liver oil, and the inunction of oil 
externally. 

STROPHULUS. 

This disease, popularly known as the red gum, tooth-rash, white 
gum, or red gown, a u papular " rash observed in children, is 
looked upon usually as the lichen of infants. But the fact is 
that under the term a number of dissimilar things have been 
mixed up together. 

The older authors described the disease as one of acutish aspect, 
characterized by the appearance, on the most exposed parts, the 
face especially, but also the neck, arms, and limbs, of successive 
crops of little red, irregularly dispersed or slightly aggregated, 
acuminated papules, intermingled with more or less erythema. 
The papules vary in size from pins' heads to small millet seeds ; 
are attended with itching, sometimes slight moisture, and desqua- 
mation. Willan made several varieties, as follows : — S. inter- 
tin ctus, confertus, albidus, candidus, volaticus ; and in addition, 
Hardy and Bazin have described a mixed form under the name of 
S. pruriginosus. 

In S. intertinctus the papules were described as vivid red, and seen 



154 STROPHULUS. 

about cheeks, forearm, and back of hands ; they are especially 
characterized by the intermixture of red blushes (erythema), and 
are intertinctured, in fact. It is said to occur in young infants, 
under three months generally, and lasts from two to four weeks. 
When the papules are numerous and closely packed — confluent — 
the name S. confertus is used. There is less erythema here ; the 
papules are paler, the disease is of longer duration than the last, 
and a recurrence is likely. This variety occurs about the period 
of dentition, and in a chronic state is often limited to a few 
patches, which run through a slow course, and leave the skin 
harsh and dry. The nature of these papulse I shall explain in a 
moment. 

S. volaticus is a term applied to the disease when it consists of 
small ephemeral patches, made up of a dozen or so of papules, 
the skin being somewhat hot and itchy. This variety is observed 
about the arms and cheeks. Patches spring up here and there for 
two or three weeks. It is in reality an urticaria (lichen urti- 
catus). 

S. albidus is the name given to another variety, but it is a 
misnomer. The name is applied to small papular elevations, per- 
fectly white, which make their appearance about the face and 
neck, and are distensions of the little sebaceous glands of the skin. 
(See Diseases of Sebaceous Glands.) 

In S. candidus the papules are large and whitish ; they are 
seen intermingled with those of S. confertus ; appear about the 
shoulders, flanks, and arms of children about a year old, and dis- 
appear in seven or eight days. It is only S. volaticus. 

Strophulus pruriginosus is the name given by Hardy to a lichen 
in which the papules are pruriginons ; it is an obstinate form of 
disease, and a not very rare one. It occurs in young children from 
a twelvemonth or so to eight or nine years of age. Papules appear 
pretty generally over the body ; they are harsh, dry, discrete, not 
confluent ; some are surrounded by a red blush. These papules 
itch considerably, are scratched, and then the apices become dis- 
coloured from the drying of a little exuded blood, as in prurigo, 
but it is often only a very minute dark speck. After a while the 
papules are covered by scaliness, and the skin looks dirty and dis- 
coloured. Ecthymatous pustules may result from the continued 
scratching. The chief seats of the disease are the back and front 
of the chest, the arms, and the face. The disease is mostly 
chronic. It follows as a consequence of uncleanliness, bad living, 
the want of fresh air and proper ventilation in dwellings, and is 
frequently seen in hot weather, and in fact it is a pruriginous 
condition consecutive to urticaria (lichen urticatus) in mal-hygiened 
or mal-fed or strumous children, and nothing more. 

Pathology and Cause of Strophulus. — It is often said that strophu- 
lus and lichen are one and the same thing in essence, strophulus 
occurring in the delicate and vascular skin of infants. After 



STROPHULUS. 155 

adolescence the nutrition of the body has so far changed, that the 
skin has become firmer and less elastic, so to speak, and strophulus 
does not occur. It is also said in books that in children simple 
disorders of the stomach lead to blood changes, and that these 
readily influence the skin, producing strophulus, as do acidity, bad 
milk, teething. I cannot subscribe to this. The strophulus of 
authors is an incongruous mixture of diseases. I believe that 
whereas the anatomical seat of lichen is the papillary layer of the 
derma, in what is often termed strophulus it is the sweat follicles. 
The summer of 1868 supplied me with a good deal of material, 
and in cases which had all the appearance in children, of stro- 
phulus, the papillary elevations were clearly seen with a powerful 
glass to be seated at the sweat follicles, and on viewing them in a 
slanting direction the central dark apertures of the pores were 
distinctly observable. When one remembers that in cases of 
strophulus the children attacked are those who are kept in heated 
rooms, or are muffled up from the fresh air — that the disease 
occurs during change of season, and on exposed parts — it will be 
readily conceived that the view I take of it may be the correct 
one. I think, therefore, that the simple forms of strophulus 
should really be ranked as hyperemias under the head of disorders 
of the sweat glands. 

Now that children are not kept so warm, and allowed to breathe 
fairly, we do not see so much of strophulus. S. albidus I entirely 
discard; it is a sebaceous disease ; and S. volaticus I expunge from 
the list of diseases. In contrasting the papule of a lichen and 
strophulus, there is every difference found : that of lichen is not 
removable by the finger, and it is solid feeling (exudation) and 
pale ; that of strophulus is vivid red (vascular), diminishable by 
pressure, and sof tish to the feel. 

Diagnosis. — In strophulus, the so-called S. intertinctus and con- 
fertus, the papules have an exanthematous aspect which is' very 
significant. As a rule, they are not so dry and harsh as those of 
lichen. The disease occurs peculiarly in infants ; it is not accom- 
panied by a harsh state of skin, by crackings, or the formation of 
crusts; it is more intermitting in its aspect than lichen. S. 
pruriginosus I relegate to lichen urticatus (urticaria). 

Treatment. — In simple strophulus cleanliness must be observed ; 
the child must not be too much wrapped up, and should have 
proper food ; the use of soap must be avoided ; the state of health 
of the nurse should be seen to ; local irritation — e. g., that of 
teething, hot clothing (flannel), must be remedied ; any aphthous 
state of mouth must be treated ; acidity should be corrected, and 
gentle aperients given ; whilst tepid sponging, spirit or alkaline 
lotions, may be used locally. A very useful lotion is, carbonate of 
soda 20 grains, rose-water 6 ounces, with 2 drachms of glycerine. 
Almond emulsion and lime-water may be also used. 



156 PRURIGO. 



PRURIGO. 



This disease is essentially a chronic inflammation of the skin, 
which expresses itself in the first place by the development of 
peculiar papulae, and subsequently general thickening of the skin, and 
moreover by intense pruritus at every stage of its course. It is a 
very uncommon disease in England, emphatically so in its severest 
form, which is seen pretty often in Vienna. 1 have been on the 
look-out for a case of the most marked form of disease, such as 
Hebra describes, for years past, and have only met with one case 
in England. 

In describing prurigo, it is most necessary to state what prurigo 
is not, for the reason that the word prurigo has been applied to 
several entirely distinct diseases in the loosest manner possible, 
and there is an abiding desire to rank under it diseases the most 
diverse en masse. I will therefore give in detail the characters of 
true prurigo, and then enter into particulars relative to the various 
diseases that have been and are likely to be confounded with it. 
The disease, I may say here, is not ptheiriasis (prurigo senilis of 
older authors). 

Prurigo occurs in two forms — a slighter and a severer form, to 
which the terms mitis and ferox, or agria, may be respectively 
applied. 

Prurigo mitis is characterized by the development of flesh-coloured 
papules, in an isolated and scattered form, of the size of a couple of 
pins' heads put together, or a little iarger. These papular forma- 
tions are attended by intense pruritus, which induces the patient 
to scratch and to excoriate the papules, which then become covered 
at their apices by dried blood-scales. Sometimes the papules are 
very deeply excoriated. There are also papules to be felt rather 
than seen on the skin, and if the finger be passed' over the affected 
part they feel shotty and hard. There are in addition to the actual 
excoriated papules and sub-epidermic papules, independent ex- 
coriations, and sometimes wheals produced by the scratchings. 
The eruption therefore consists of certain papules, altered by 
scratching, and accompanied by intense itching, as primary and 
essential phenomena. The pruritus is often of a burning or creeping, 
or intensely itchy character; it is aggravated by alterations of 
temperature, by the access of air to the skin, by mental emotion, 
by the ingestion of food, especially spicy things and hot liquids. It 
keeps the patient awake at night in some cases for hours together. 
The seat of the eruption is, particularly, the exterior surface of the 
legs and arms, the buttocks, and the shoulders about the scapulae. 
In some cases about the legs, the papules crowd together, forming 
a patch, which is increased in size and thickness by general in- 
flammatory infiltration of the part, which then feels hard, rough, 
and indurated like thick leather. I have seen this disease in most 
cases in cooks or others who have been exposed to the fire a great 



PRURIGO. 157 

deal, and the innervation of whose skin has clearly been thereby 
much perverted. The disease has occurred in these cases in men 
and women of from twenty to fifty years of age. I have seen some- 
tiring like the disease in a more localized form result after chronic 
eczema in young children. 

Prurigo ferox, or agria (Iiebra's prurigo). This severer form of 
the disease, which occurs at an early age, is said to be incurable. 
It affects the general surface of the skin, and is characterized by 
general infiltration into the skin, with certain secondary con- 
sequences, such as abscess. It is supposed not to occur in England, 
but I have recently, as before stated, seen an undoubted case. 
This form of disease has been specially described by Hebra, and it 
is common in Vienna. The reader will readily understand that if 
the simpler form of disease were to become very exaggerated the 
papules would crowd together, and this, together with inflam- 
matory infiltration of the skin generally, would give rise to a form 
of disease in which the whole skin is rough, harsh, and thickened, 
and in which, if the patient be cachectic, eczema, pus-formation, and 
the like, with glandular complication, may result. Such is Iiebra's 
prurigo indeed. But Hebra shall speak for himself. He says : — 

" Its earliest sign appears in the form of isolated sub-epidermic 
papules recognisable rather by touch than by sight, raised but 
little above the level of the skin, and not differing from the latter 
in colour, appearing in various parts of the body. They are ac- 
companied by great irritation, and being scratched become red and 
raised, and at length covered over by a black scale of dried blood, 
and presenting then the features of an ordinary pruriginous rash. 
When this state has lasted for some time, a series of fresh phe- 
nomena appear. There is an increased deposit of pigment observed 
in the skin in the seat of the excoriations ; the natural furrows 
become more distinct and separated, especially about the wrists, 
the back of the hands and fingers ; the hairs thin out ; the skin 
gets more dense and hard, and feels much thicker. But this is not 
all ; occasionally an exaggeration of these phenomena are observed 
(P. ferox), the itching increases, the papules enlarge, the excoria- 
tions and blood-crusts are more developed and abundant. The 
epidermis peels off as a powdery substance, and suppuration of 
each papule may occur, or a condition of eczema rubrum may be 
produced in a part or over the whole surface." 

Hebra adds : " Going over the different regions of the body in a 
patient affected with prurigo, we shall find the scalp free, but the 
hair dry and covered over by a scaly dust ; the face clear or showing 
a few papules, save in rare cases, when it is eczematous ; the throat 
and back of the neck free ; the whole thorax, however, in front and 
behind covered with papules, some only to be recognised by touch, 
others being ' pruriginous ' (as we English understand). The abdo- 
men is likewise affected, so also are the buttocks and sacral region ; 
but the limbs show the disease most certainly, especially on the 



158 



PRURIGO. 



exterior surface. The skin is discoloured and thickened, and fur- 
rowed also, especially over the exterior surface. The leg below 
the knee presents the most characteristic appearance and feel, 
being as rough and harsh as a file. The armpits, hams, flexor 
side of wrists and palms, groins, and soles of feet are unaffected. 
If there be much eczema, the glands are enlarged (prurigo buboes). 
The disease begins in early life, varies in severity, lasts a lifetime, 
and is incurable. It occurs in the badly nourished, and is aggra- 
vated by winter." 

Fig. 13. 




Section of pruriginous skin from leg. a. Epidermis, b. Pigmented 
rete Malpighii. c. Thickened corinm with enlarged papillae. 

It will be observed then that prurigo ferox commences in the 
same way and form as prurigo mitis, and becomes subsequently 
exaggerated. I can now confirm Hebra's description from personal 
experience of the disease as seen in England. I will only add that 
I have seen a condition suspiciously like partial prurigo result from 
chronic eczema in bad-hvgiened and badly-fed subjects. 

Morbid Anatomy. — The changes that occur in the skin in prurigo 
have been pretty well made out. Neumann found a limited cell- 



PBTTKIGO. 159 

growth in the papillary layer of the skin, with much amorphous 
matter. The rete Malpighii and horny layer of the epidermis 
being both hypertrophied, with great increase of the stellate cells. 
Derby, of Boston,* describes similar changes as occurring in well- 
developed cases, but declares that a hair runs through the centre 
of each prurigo papule, there being a great increase of connective- 
tissue cells at the point of insertion of the arrectores pili. This 
Neumann denies, stating that the cell collections which are seated 
above or below these muscles are the same as those seen in lichen 
planus. In marked cases the cutis is generally thickened by hyper- 
trophous growth, and so is the outer root sheath. Hebra thinks the 
papules are not formed originally at the papillary layer, as stated 
by Neumann, but by effusion into the deepest strata of the epider- 
mis. Yery recently some further investigations have been made by 
Dr. A. Gay, of Kasan,f with great care and minuteness. 

Dr. Gay states as the result of his examination that the pruri- 
ginous process begins, as stated by Neumann, in the papillge of 
the corium, the texture of which becomes considerably richer in 
cells, whilst its vessels are enlarged. 

The rete Malpighii is involved, its cells proliferating, especially 
in the deeper layers, whilst numerous small cells are met with 
which probably originate by a segmentation of others. The rete 
Malpighii thus becomes hypertrophied. But the corium also 
thickens. Cell proliferation is likewise noticed in the fundus of the 
hair follicle, in the outer root sheath, especially in certain places 
in it, and also in the hair papilla and the hair bulb. 

In chronic prurigo the hair is frequently found with its inner 
sheath torn off at the upper part of the outer sheath, except in those 
places where the latter has formed protrusions. 

" The sweat glands participate in the process in a very marked 
degree ; the cells of the excretory duct and glandular canal are 
cast off from the walls ; at the same time numerous small, round, 
and branching cells are observed in their walls. By the ad- 
vancing morbid process all the parts of the corium are changed like 
those in the papillary texture at the beginning of the process ; the 
vessels are enlarged, the texture filled with numerous cell forma- 
tions ; these are either small, round cells, easily tinged in carmine, 
or large, irregular, migratory cells filled with one or more 
constricted nuclei, nets of branching cells, and in the chronic 
form whole tracts of spindle-cells; in the latter case the blood- 
vessels present in their coats a considerable cell increase." 

Diagnosis. — In thus endeavouring to give for the first time a 
distinct and clear account of prurigo as an independent disease, 
it is very necessary to make a few remarks upon the varied inter- 

* Sitzungsberichte d. Kais. Akad. , 1869. 

f See a full translation by Dr. Kuentzler, of the article of Dr. Gray (originally 
published in the Archiv fur Derm, und Syph.) in the American Journal of Syphi- 
lography and Dermatology for July, 1870, p. 261. 



160 PRURIGO. 

pretations put upon the term " prurigo " by different writers. It 
is only recently that dermatologists have come to the conclusion 
that there is an itchy and papular disease of the skin of idiopathic 
origin, to which the term prurigo should be applied. 

Under this term have been mixed up because they have not been 
properly diagnosticated : — 

1. Phtheiriasis, or the disease due to pediculi. 

2. Pruritus, with the results of scratching, or so-called " prurigi- 
nous " eruptions occurring in connection with local irritation, 
and independently of senile decay. 

3. Pruritus and changes in connection with senile decay of the 
skin (pruritus senilis). 

4. True prurigo. 

The first three will be or have been described ; the first undei 
parasitic diseases, the second under the head of follicular conges- 
tion, and the third under neuroses of the skin. 

The term " pruriginous," which has been used as I have elsewhere 
stated to describe any papular rash the result of scratching, and 
which is characterized by excoriated papules with dark apices due 
to dried blood, is an unfortunate one, because it implies some con- 
nection with prurigo ; indeed, I prefer the term " pruritic rash," or 
pruritic " eruption." (See Follicular ITypersemia, p. 127). 

Willan made three varieties of prurigo — mitis, formicans, and 
senilis ; and according to my opinion his prurigo must be broken up 
and its varieties distributed as follows : — The prurigo mitis and for- 
micans constitute the slightest forms of true prurigo — prurigo mitis. 
His prurigo senilis is a combination of phtheiriasis and the pruritus 
with " pruritic eruption " accompanying senile decay of the skin. 

The upshot of the whole matter then is simply this — that prurigo, 
phtheiriasis, and pruritus senilis are quite distinct and separate 
diseases. Prurigo is known by the presence of solid fleshy papules 
of primary origin, accompanied by intense itching, and in severer 
cases by the general infiltration, the prurigo buboes, and the raspy, 
rough, knotty feel of the skin of the limbs. 

Causation. — Nothing is really known as to the causes of prurigo. 
It may be that nerve paresis is at the root of the disease, but it is 
mere guesswork at present to say so. 

Treatment. — The success of treatment in the severer form of 
prurigo depends upon the fact of the attacked being a child ; for 
by j udicious treatment in the child the disease can be cured. The 
slighter form (P. mitis) one can always cure. In treating the 
disease, the objects to be attained are — the improvement of the 
patient's general health ; the removal of the patient from all in- 
fluences that stimulate the skin, such as his or her remaining in 
an occupation which entails exposure to high or great variations 
of temperature ; the quiescence of the pruritus ; and the removal 
of the infiltration into the skin. As regards improving the general 
health, this is very necessary in certain cases. In two or three 



PRURIGO. 161 

instances patients who have come under my care with prurigo 
mitis have been greatly troubled and worried, they have been very 
dyspeptic, and have taken by far too freely of stimulants in place 
of solid food. If therefore the system be loaded with retained 
excreta, if there be dyspepsia, appropriate medicines to remedy 
these conditions must be adopted in accordance with general rule. 
In the severer cases quinine, steel, and cod-liver oil are clearly 
indicated. The pruritus may be relieved by the employment of 
baths, emollient applications, and the use of anodynes and sedatives, 
both external and internal. Anything that allays the pruritus 
tends to favour the cure of the disease. But there are other and 
special remedies which speedily act in this direction, to be noticed 
directly. I have the greatest faith in strong alkaline baths, 
following up by the application of any bland oil or of unguent kept 
in contact with the skin all night, and the use, if the patient must 
go about his business, in the daytime, of an oxide of zinc or borax 
and prussic acid lotion, &c. (Nos. 53, 47, 51, 54). 

I think it is very important that the air should be excluded from 
the excoriated and scratched skin. The baths should have a tem- 
perature of 92° to 94° F., and contain 2 or 3 lbs. of clarified size, 
with 2 to 4 ounces of bicarbonate of soda in each. The patient 
should remain in the bath twenty minutes, and be well oiled over, or 
wrapped up in oil or unguent for the night on coming out of the 
bath. The best unguent is perhaps the old " Kirkland neutral 
cerate," freshly made. If the baths do not allay irritation, some 
more decided sedative may be applied externally. (See Formulae 
Nos. 37 ? 38, 40, 44, 46, 49, 57, 59, 64, 76, 88, 108, 130, 131.) 
The patient should take chloral at night. If the disease assumes 
an indolent but yet not a severe form, I have recourse, in addition, 
to the use of tar or sulplmret of potassium baths, for the purpose 
of stimulating the skin, but I object to push their use if they irritate 
in the least. At Vienna the soap treatment is recommended, but 
I cannot get any good out of it in England. For the treatment of 
very obstinate cases I should be inclined to try alterative doses 
of bicyanide of mercury in l-24th grain doses twice a day, 
with cod-liver oil and alkaline and sulphuret of potash baths alter- 
nately, followed up by oil inunction and the occasional use of tar 
compounds, the best being the pyroligneous oil of juniper, 3 ij to 
| ss or | j of lard. But as I have only seen one of the severest 
cases, and that recently, and it is still under care, I cannot offer 
much advice as regards the treatment of such cases. 
11 



CHAPTEE X. 

CATARRHAL INFLAMMATION, OR ECZEMA. 

I consider it very necessary to give a pretty full account of 
eczema, because I venture to hold opinions which coincide with 
those of Willan, and are therefore opposed pathologically to the 
views of many modern authorities and writers upon the subject. 
I will first state what eczema appears to me to be, and then append 
and examine the views of others. Now in estimating the 
nature of eczema, it is imperatively necessary to deal with the 
disease in all its parts, as one whole. There is a tendency amongst 
the best observers to base their conclusions as to eczema and its 
relationships upon partial views of the disease. For instance, some 
seem to concentrate all attention upon the pathological lesions, 
some upon the physical characters of these lesions, &c. But a 
correct estimate of the disease can alone be obtained by taking 
these lesions in conjunction with the general history and course of 
the disease, the subjects in whom it occurs, and other concomitant 
considerations. 

In the preceding chapter I have dealt with diseases charac- 
terized as regards local changes by hypersemia, and consequent 
serous effusion into the rete. In eczema there are present not only 
hypersemia and serus effusion, but distinct changes in the tissues 
of the deeper parts — the papillary layer and the corium — giving 
rise to new products, and especially pus. These changes are 
primary and essential phenomena; in fact, true inflammation, in 
the fullest sense of the word, is present. 

The leading idea I would have my readers keep in view in 
dealing with eczema, is, that it is the analogue of catarrhal inflam- 
mation of the mucous membrane ; in fact, the disease is catarrhal 
inflammation of the skin. This view of the character of eczema I 
have long put forward, and on referring to Rindfleiseh* I was very 
glad to find eczema regarded as a catarrh of the skin. 

But I will proceed to give a general description of eczema, and 
will deal with the views of authorities subsequently and sepa- 
rately. 

Now, typical eczema is an acute inflammatory disease, charac 
terized especially by an eruption, in connexion with more or less 
superficial redness, of small closely-packed vesicles, which quickly 

* Text-book of Pathological Anatomy. 



CATARRHAL INFLAMMATION, OR ECZEMA. 163 

run together, burst, and are replaced by a slightly excoriated 
surface that pours out a serous fluid, which dries into crusts of a 
light yellow colour, of moderate thickness, and composed of granu- 
lation corpuscles, pus corpuscles, epithelial cells in an ill-deve- 
loped state, and granular matter of an inflammatory and fatty 
nature. The discharge has the very peculiar property of stiffening 
linen. The vesicles appear in successive crops, and may prolong 
the disease for an indefinite time. Their formation is attended 
with itching and local heat. The skin is irritable, and occasion- 
ally excoriations or crackings of the part occur. The true skin 
itself is somewhat infiltrated, and sometimes the parts around the 
patch inflame, in some cases from the irritating nature of the 
discharge, whilst the disease is very apt to spread. The patches 
form on various parts of the body, are of variable size, and they 
are mostly symmetrically disposed. The discharge of an eczema 
may, however, be not serous but mainly purulent, and then large, 
thick, yellow crusts form. As the disease progresses towards cure, 
the discharge ceases, and a reddened scaly surface remains. If 
the disease is extensive and general there may be sharp pyrexia. 
Generally speaking, the attacked are of lymphatic aspect, and 
they often suffer from headache, loss of appetite, thirst, foul 
tongue, confined bowels, and the like. The mucous surfaces may 
become the seat of inflammation, either by the spread of disease 
from the skin or as a consequence apparently of the general con- 
dition. The disease is the most common of all skin diseases ; it 
lasts a varying time, in consequence of successive local develop- 
ments, and the tendency it has to spread. In the chronic state it 
often oscillates between cure and recurrence ; the skin gets harsh, 
dry, red, and thickened from infiltration with new inflam- 
matory products. After its disappearance, the disease usually 
leaves no traces of its former presence ; but if eczema last a long 
time induration, fissures, oedema, papillary hypertrophy, ulceration, 
&c, may ensue ; but these are quite accidental and secondary. 

Now this typical form of eczema is not often seen by the prac- 
titioner in the early stage at which the vesicles are visible ; but 
for all that it does exist. The varieties of eczema are three — 
Eczema simplex, localized and without appreciable general 
symptoms ; E. rubrnm, more or less general and inflammatory 
in its attack, as regards not only its local inflammatory phenomena 
and implication of the deeper tissues but the disorder of the 
system generally ; and lastly, E. impetiginodes, in which the 
pus formation is not accounted for by the degree of inflammatory 
action, but is clearly dependent upon the existence of pyogenic 
habit of body. Each of these varieties has, more or less perfectly 
marked, its stages of erythema, papulation, vesiculation, pustula- 
tion, and squamation; these mere stages cannot be regarded, how- 
ever, as constituting clinical varieties of eczema. These varieties 
all come under the definition of eczema as a catarrhal inflammation 



164 

of the sJcvriy which is mainly characterized by a peculiar discharge, 
stiffening linen, and' drying into thin yellow crusts, and having its 
stages of erythema, papulation, vesiculation, discharge, pus forma- 
tion, and squamation, more or less marked under different circum- 
stances / and followed in some cases by the secondary results of in- 
flammation, such as hypertrophy, oedema, and the like. 

E. simplex (called by WHlan when slight E. solare, because it 
is often brought into existence as a consequence of the action of the 
sun's rays), is the typical form. It is generally local, but may be 
more or less general. It is excited by irritants of all kinds — e.g., heat, 
cold, soap. If it occur in summer, the patient complain of fever, 
"heated state of blood," headache, and the like ; presently, on the 
exposed parts, especially the face, arms, neck, or the back of the 
hands, little clustering vesicles about the size of pins' heads appear, 
in conjunction with the slight erythema, heat, and itching. The 
contents of the vesicles presently get milky, the vesicles burst, 
and slight yellowish crusts are formed. The duration of the 
disease varies very considerably. It is often short, but may be pro- 
longed sometimes by the continued springing up of fresh crops of 
vesicles. 

E. rubrum is the inflammatory form. The general symptoms are 
often severe ; headache, fever, thirst, and foulness of tongue, being 
present to a marked degree ; locally the part is " hot, tumefied, 
red, and shining," and upon this vesicles (which may require the 
use of a lens to detect satisfactorily) form, and soon become con- 
fluent, These vesicles very speedily burst, give exit to their 
contents, which desiccate, and give rise to yellow or brownish 
scabs ; the secretion is ichorous in character, and causes conside- 
rable irritation to the surface around with which it may come in 
contact. The whole patch becomes excoriated, the burning pain 
is often very severe, and the disease spreads. This variety of 
eczema is generally observed about the flexures of the body, in 
the thigh, the groin, the elbow, the axillae, and about the wrists ; 
sometimes it is partial, but it may spread widely over the general 
area of the body. E. rubrum varies in degree ; when it is very 
severe, the amount of discharge is large, the crusts are thick, 
the surface is much inflamed, and excoriated to a high degree. 
The transition from the simple to the inflamed variety of eczema is 
easy. E. rubrum is apt to become chronic in old people in whom 
it occurs about the legs, and is oftentimes the starting-point of 
ulcers. 

Eczema Impetiginodes. — This is eczema occurring in lymphatic 
or debilitated subjects, especially young children, and since there 
is more or less of a pyogenic habit present, the corpuscular 
element in the secretion is much in excess, the amount of pus 
bearing no relation to the intensity of the inflammation. The 
general symptoms are in many instances much the same as those 
of eczema rubrum. There are, locally, a good deal of inflamma- 



CATARRHAL INFLAMMATION, OR ECZEMA. 165 

tory heat and redness ; the vesicles which appear contain a 
serosity, which is speedily mixed with purulent secretion. The 
discharge and subsequent drying of this tenacious fluid forms 
irregular greenish-yellow thick scabs and crusts, beneath which 
is a red ichorous surface. This form of eczema is very com- 
mon, and is not as a rule general but local, confined often- 
times to a limited surface. This variety occurs especially in 
the head, and in infants. In infants the sebaceous glands often 
become irritable, and pour out a large quantity of fatty matter, 
and the disease is thereby increased in severity. The description 
of eczema infantile to be given directly will apply to the severest 
forms of eczema impetiginodes. 

Impetigo. — In some cases of E. impetiginodes, or E. pusttdosum, 
the pus formation is very rapid and the vesicular stage is not readily, 
if at all, observed. It is this form of disease to which the term 
impetigo was given. The older writers described it as charac- 
terized by the presence of psydracious pustules, or elevations of 
the cuticle by small collections of pas which run together ; the 
increased production of pus, sometimes at different points, augment- 
ing the area of the purulent patch often to a large size. The pus 
is soon discharged by rupture of the cuticular wall and then dries 
into thickish yellow crusts, accompanied by more or less oozing. 
The disease, in fact, is an infiltration of pus beneath and in the 
deep layers of the cuticle. Now when the patches are small and 
scattered, the disease is called impetigo sparsa (scattered) ; when it 
occurs in a large irregular patch, I. figurata. When the discharge 
is free, and there is a heaped-up and thick crusting from the 
drying and collection of the secretion, it is termed I. scahida, and 
occasionally the deep tissues the inflamed, and then we have I. ery- 
sipelatodes. Impetigo figurata may discharge a tenacious fluid, 
which, at first is very much like " concrete honey " (hence the 
name, Melitagra) ; but the crusts presently become dry, yellow, and 
discolored. This phase of pustular eczema is generally observed 
on the face. When the discharge is free, as in infants, the scabs 
may be " stalactitic ;" hence also the terms crusta lactea, porrigo 
lar.valis. 

Two other forms are described by authors, I. sycosiforme and I. 
acniforme. The former is really I. labialis, in which there is a 
good deal of swelling and tension, and the discharge heaps up 
into honey-like crusts, often just beneath the septum nasi. The 
latter is a suppurative inflammation of the hair follicles of the 
beard, and is often confounded with parasitic sycosis. But this 
impetigo of the beard is often an acute affection. There are 
impetiginous spots about the face outside the beard ; it affects 
quickly at the onset a large extent of surface ; it is more superfi- 
cial than the parasitic variety, has more crusting, the hairs in the 
follicle are not loosened or rendered dry and brittle, and there is 
no fungus present. The disease may become chronic. 



166 

Secondary Changes in Eczema. — Any of the three chief varieties 
of eczema may become chronic, and in some cases the amount of 
discharge may be free and irritating. This state has been called 
E. ichor o sum : or the discharge may not be sufficient to give rise 
to continuous crusting, bnt what is apparently only scaliness. 
This phase of disease has been termed eczema squamosum. If cracks 
occur, a raw red, perhaps an exuding, cracked surface, termed 
E fissum (E. fendille of the French) results. Fissures are often 
produced from the movements of the mouth. Again, induration 
may be a consequence, or the skin about an eczema may become 
(edematous or warty, or specially thinned, or the fibrous struc- 
tures may greatly hypertrophy, and a huge, shapeless mass, with 
free ulceration, result. Hence other varieties haA r e been made, 
such as E. oedematosum, verrucosum, sclerosum, spargosiforme, and 
so on. But really to dignify all these secondary changes by an 
elevation to the position and rights of special varieties is to me 
highly objectionable. The induration, papillary growth, and the 
like, have their origin really in special deviations of the tissue 
nutrition itself, the result of hyperaemia. There is not so much ec- 
zema present in these cases, as accidental conditions of hypertrophy 
or atrophy which frequently occur when eczema is absent as well as 
present. Eczema squamosum and pityriasis are often regarded as the 
same. In the former, the scaliness is secondary, in the latter (pity- 
riasis), a primary item of disease — two totally different conditions. 
In some cases the " discharge " feature of eczema is not so well 
marked as in others. It may be but slightly marked, and then 
the erythematous aspect may predominate, the exudation may be 
slight, and only raise the cuticle into what appears to be papu- 
lation; or pus may be readily produced, or the secretion may 
quickly be reabsorbed, and scales be produced, or fissuring 
result at an early stage. It has been therefore said that eczema 
may commence as an erythema, a papulation, a vesiculation, a 
pustulation, a squamation, or a fissure. Now I admit that any of 
these stages of inflammation may be quickly arrived at, or certain 
of their characters be specially preserved. But in all cases the ten- 
dency is to the outpouring of a large quantity of serosity of srjecial 
quality from the skin, as one of the characteristic occurrences. This 
outpouring of fluid necessarily tends in the first place to uplift 
the cuticle — i.e., to the production of vesiculation, which rapidly 
disappears, because the cuticle bursts and discharges the fluid; 
but the tendency to free secretion exists, and is the main feature 
in the disease. I stated before that this vesicular stage has 
generally passed when the disease comes under the notice of the 
physician, though vesiculation may, with care, be made out at the 
edge of a patch which is on the increase. It is manifestly unfair 
to estimate the value to be attached to vesiculation, or its probable 
frequency in cases of eczema, from a consideration of such cases as 
are stationary or in progress towards recovery. 



CATAEKHAL INFLAMMATION, OR ECZEMA. 167 

So far then I have described the standard varieties of eczema 
and their immediate consequences ; I now proceed to speak of the 
peculiarities of these varieties of eczema as they are observed in 
different parts of the body. 

E. Infantile. — This has the characters of eczema rubrum and ecze- 
ma impetiginodes more or less combined. There can be no doubt 
that it is a very obstinate and severe disease. One often sees this 
form of eczema running through almost all the stages represented by 
the disease collectively. It generally commences in the very young 
child as an acute attack, subsides into a chronic state, which may 
last for a very long time, even years. The child is thin, pale, 
pasty, takes food badly, &c. When the eruption first appears its 
aspect is really a compromise between E. simplex and E.. rubrum ; 
the discharge then alters its character, and E. impetiginodes is 
presented to us. The local signs of irritation are more or less 
marked; there are heat, itching, pain, swelling, excoriation, rawness, 
or ulceration ; the secretion may be thin or purulent, the glands in 
relation to the scalp — ex., behind the ears, and at the occiput and 
in the neck are swollen, and according to the aspect of the part 
attacked, whether moist or dry, the disease has received various 
names — e.g., tinea granulata, crusta lactea, porrigo larvalis. It 
affects all parts, but especially the scalp, buttocks, axillae, ears, and 
flexures of the joints. The child gets feverish, it loses flesh, and 
marasmus may supervene. If not properly treated, the disease 
becomes very chronic, and the child a pitiable object. In children 
who are somewhat bevond the babv age the disease is seen during 
dentition, in scrofulous children especially. When it attacks the 
scalp pediculi are common among the crusts. 

Eczema capitis has been partly described, a moment since under 
the head of E. infantile, as it occurs in the young. In the adult the 
symptoms of eczema capitis are often very severe. After the acute 
stage is passed, which is that of E. rubrum chiefly, the secretion 
dries, and the whole scalp may present a raw, red, cracked surface, 
covered over more or less with lamellar scales of yellowish tint, or 
crusted all over. If there be hair on the head the discharge mats 
it into masses, and the hair formation is checked — that is to say, 
the hair is " thinned." In the process of cure, a state like pityriasis 
is produced. The disease is often very obstinate. In children 
pustular eczema (impetigo) is often excited by pediculi. 

E. faciei is often an extension of the disease from the scalp ; 
the secretion in this local variety is free, and forms large crusts, 
generally on the forehead, but also the cheeks and chin. The con- 
junctivae are often red and tender. Itching is very troublesome. 
The disease is mostly symmetrical, and does not present an uniform 
aspect ; here it is inflamed and red, there it is crusted over ; here 
pustular and there cracked, perhaps. Like the E. capitis it is 
often confounded with seborrhcea. 

Eczema labialis takes the form of eczema impetiginodes usually, 



168 

but 1 have met with an unusual form of disease, or one at- 
tended with unusual results, which I may briefly notice here. 
The patients, who were both men, stated that the disease arose 
from a cold ; that then the upper lip enlarged gradually so as to 
produce considerable thickening and swelling. It so happened 
that on one occasion a distinguished foreign dermatologist was 
present, and he suggested that the disease was of the nature of 
epithelioma ; but the rapid cure and the history of the cases en- 
tirely set aside this explanation. When first seen the disease 
consisted of a swelling extending half an inch laterally from side 
to side of the fraenum of the nose, and from above downwards to 
near the junction of the mucous membrane and skin. It was, in 
fact, an oval swelling, the skin being raised about three or 
four lines. The swelling felt elastic ; it was not hard, but it was 
tender, and smarting was often felt in it. The colour was inflam- 
matory. On close examination the hair follicles were seen to be 
more distinct than usual, and to be pustulating at their apices. 
There were here and there slight crusts. The hairs of the moustache, 
which had been cut off close to the lip, were not loosened nor 
altered in texture ; but on pulling at them, much pain was at once 
experienced. In fact, it was, perhaps, the papillated aspect given 
to the general swelling by the enlargement and projection, so to 
speak, of the follicles that led to the idea of the disease being 
epithelioma: but, on careful examination, it was seen that the 
disease was clearly produced by inflammation of the hair follicles, 
implicating the fibrous tissue round about to a greater extent than 
usual. The history showed the case to have commenced by the 
extension of a catarrh from the mucous surface to the hair follicles. 
There was no free crusting, as in ordinary impetigo labialis. The 
disease might have been termed by some non-parasitic sycosis, 
which is or course nothing more or less than catarrhal inflam- 
mation of the hair follicles ; but in the above instances the 
aspect was not so distinctly pustular as is usual in inflammation 
of the hair follicles about the face, and the swelling of the deep 
fibro-cellular structures was very marked — much more marked 
than usual. The disease began as an eczema, involving the parts 
about the hair follicles. I have met with many instances of the 
condition now described ; and am emphatic in condemning the 
use of irritants, stimulants, or active absorbents in the early 
stage of the disease. All these remedies increase the follicular 
irritation. The use of litharge ointment so as to exclude the 
air, after hot fomentations, the avoidance of stimulating things, 
with alkalies and tonics internally, and subsequently strapping 
with lead or mercurial plaster, and the use, in the very chronic 
stage, of iodine, are most serviceable. But the avoidance of 
irritating applications, in the early stage, is the most important 
point to remember in reference to the treatment.* 

* Lancet, Aug. 6, 1870. 



CATARRHAL INFLAMMATION, OR ECZEMA. 169 



3. E. aurium is another sub-variety. The ear is red, swollen, 
tender, hot, and tense, the vesicles are often very well developed, 
and the discharge free, drying into crusts, which after falling, 
leave behind a dull red surface. The disease often extends into 
the meatus, causing swelling and blocking-up of the passage. 
More frequently, E. aurium takes on the aspect of E. impetigi- 
nodes, then the ear gets hypertrophied, and small abscesses are 
formed. In old people the ear is often affected. The disease is 
very obstinate. 

4. E. mammw is observed during lactation more especially, and 
is confined to the female sex. It is observed around the nipple, 
and the degree of inflammation varies : sometimes it is slight, at 
other times the aspect of impetigo is assumed, and there is often- 
times a tendency to the formation of fissures, with subsequent in- 
filtration, and threatening abscess formation in the lax cellular 
tissue beneath. The nipple is hot, tender, and often bleeds. Hardy 
says it arises out of three conditions ; in fat people, during lacta- 
tion, and in scabies, and he believes correctly that it is an excel- 
lent diagnostic sign of scabies. 

5. E. manuum et pedum is chiefly remarkable for the peculiar 
tenacity and persistence of the vesicles, due to the greater thick- 
ness in the cuticle of the hands and feet. The disease assumes mostly 
the aspect of E. rubrum on the back of the hands and between the 
fingers. The fluid in the vesicles, seated upon a red base, gets 
absorbed, and crusts are then formed ; sometimes bullse are pro- 
duced by the coalescence of vesicles ; accompanying pruritus is 
oftentimes severe. Presently the patch becomes drier, more scaly, 
thickened and fissured, the fissures giving exit to a viscid secretion 
which concretes into scales ; the disease may assume a pustular 
aspect. The grocers' or bakers' itch is according to some authors 
an eczema of this class. An acute form has been described, which 
commences by marked fever and malaise, the tissues generally are 
inflamed, bullae form, and the fluid being absorbed, large scales 
are detached, exposing a red surface, which gives out a quasi- 
purulent discharge, and this is often followed by a chronic stage. 
This is eczema rubrum. 

6. E. genitale attacks the anus, perineum, scrotum, and vulva, and 
is characterized by its very free secretion. It often commences at 
the scrotum, which is thickened, puckered, moist, and tender, 
covered with large thin scales, a thin fluid oozing freely from nu- 
merous fissures. It often extends from the scrotum to the anus and 
from the pudendum to the vagina, induces intolerable itching, and 
is attended with swelling, heat, redness, and discharge. 

Varieties have also been made according to form ; for example, 
when eczema occurs in round patches the size and shape of 
pieces of money, it is called E. nummularis.* 

* Many eczemas either become complicated with or are caused by parasitic 
growths. They certainly rapidly disappear with parasiticide treatment. 



170 CATARRHAL INFLAMMATION, OR ECZEMA. 

Eczema marginatum is the name given to a disease which is seen 
at the inner part of the thigh, or the fork. It is generally sym- 
metrical, and presents a red dry, often scaly surface which sweeps in 
a circular maimer from the fork down the thigh for several inches. 
It is said to occur in shoemakers and dragoons as the result of 
heat and moisture. It is in reality parasitic, and will be described 
under the head of tinea circinata, I believe under this head dif- 
ferent diseases are very likely to have been included — intertrigo, 
le23ra vulgaris, erythema from pedicular irritation, eczema, and 
ordinary ringworm of the surface. 

Pathology. — Speaking in general terms I may describe the morbid 
anatomy of eczema, in its earlier stages as consisting of swelling 
of the cells of the epidermis from imbibition of fluid, together with 
infiltration of serum into the substance of the corium and the rete, 
and the production of a large amount of new cell growth. The 
outpoured fluid finds its way to the rete mucosum from the papillary 
layer, separating the cell elements and uplifting the cuticle so as to 
form vesicles. The capillaries are much congested. When the 
cuticle is ruptured, the deep layers of the rete mucosum, or even 
the corium, may be exposed. In some cases the cells of the rete are 
intermingled with pus cells in great amount. As the result of the 
inflammation, certain hypertrophic and degenerative changes may 
subsequently occur in the deeper parts of the skin. 

But. it is necessary to enter into greater detail, and I may con- 
veniently refer to the pathological changes occurring in eczema in 
the early stages (acute eczema) on the one hand, and the later 
stages on the other (chronic eczema). 

First, as regards eczema in its early stage, Neumann,* in some 
experimental researches which he made as regards the artificial 
production of eczema in animals by external irritation, found that 
the earliest stage in the disease was a rhythmical contraction of the 
capillary vessels, which were now empty, now gorged, until complete 
stasis followed. Then free effusion of serous fluid occurred, with 
lively proliferation of the cell elements of the skin, especially in its 
papillary layer. This latter condition was coincident with the 
formation of vesicles. 

And as regards this point Biesiaclecki's researehes,f whilst 
they are confirmatory, add to our knowledge of the phenomena 
observed by Neumann. Biesiaclecki notices that there are always 
certain elongated cells intermingled with those ordinarily de- 
scribed as making up the rete mucosum, and that the peculiar 
cells are derived from the connective-tissue corpuscles (see fig. 2, 
p. 16). Now in acute eczema when the papillary layer of the cutis 
is being distended by serous effusion from the capillaries in the 

* Lehrbuch der Hautkrankheiten. Yon Dr. Isidor Neumann. Wien : Bran- 
rniiller, 1869 ; or Dr. Pullar's English translation. 

f Beitrage znr Physiol, und Pathol. Anat. de Haut. Sitzungsberichte der 
1867. 



CATARRHAL INFLAMMATION, OR ECZEMA. 



171 



way described by Neumann, these spindle-shaped cells undergo 
rapid changes, and appear in greater numbers in the papillary 
layer, and also migrate to the rete. They are likewise pushed 
forward to the surface, together with the cells of the rete : but 
more than this, they branch very freely, and according to Biesia- 
clecki, their branches unite so as to form a complete network of 
canals, in the interstices of which the ordinary cells of the cuticle 
lie. It is believed that through these canals, so formed, the large 
amount of fluid discharged in eczema finds its way to the surface 
so readily. Biesiadecki also affirms that pus cells, when present, 
are derived from the connective-tissue corpuscles. Others of 
course, and I referred to this in speaking of inflammation, declare 
that pus cells come from white blood cells escaped from the vessels. 
The following illustration will explain Biesiadecki's views. 

Fig. 14. 




m~a 



Eczematous papule (after Biesiadecki). a. Spindle-shaped cells, which nume- 
rously traverse the mucous layer, a' with several nuclei, a" half remaining in the 
corium. c. Papilla. 

Now in some cases the hyperemia lessens, the inflammation 
quiesces, effusion and cell proliferation cease, and the tissues 
gradually return to their normal state. In other cases the cell 
growth remains active, the outpouring of fluid continues to be 
free, and the changes are observed to extend deeper and deeper, 
and to implicate even the connective tissue below the derma ; after 
a while, the organization of the cell tissue gives rise to an inflam- 
matory hypertrophy, with more or less alteration of the vascular 



172 



CATARRHAL INFLAMMATION, OR ECZEMA. 



and other tissues invaded by the cell growth. And this leads me 
to speak secondly of the ■ 

Changes found in Chronic Eczema. — In the acute cases of disease 
the papillary layer and the upper part of the corium invaded by 
cells and effused fluid are not so far damaged but that they recover 
their normal condition. In chronic eczema, however, they remain 
engorged with new material, so that the papillae are noticed as 
veritable projections over the surface of an eczema denuded of its 
crusts. The new cell growth is observed to be particularly marked 
about the vessels, and after a while these may be more or less 
obliterated by the pressure exerted upon them, and their place 
marked by strands of pigment, which is also formed between the 
papillary layer and the rete. But the new tissue may be removed 
gradually after having undergone fatty and granular degeneration 
and absorption. 

The annexed (fig. 15) is given by Rindfleisch in illustration of 
the changes seen in chronic eczema and above described. 

Fig. 15. 




^ssgs^c^SSSI^ 



Vertical section through the skin after chronic eczema, a. Homy layer, b. Mucous 
layer of epidermis, c. Pigmented stratum of cylindrical cells, d. Papillary layer. 
e. Cutis pervaded by stripes of pigment. 

The hairs and glands cannot be distinguished in some cases. 
The papillae may be less elevated than in health, being pressed upon 
by the new tissue. But in very chronic cases these changes, due to 
infiltration, are to be seen as deep as in the panniculus adiposus. 
Fig. 16 is Neumann's representation of such a condition. It is 
not difficult to account for the obstinacy of eczema if one remem- 
bers the exact changes that go on in the tissues. 

The close analogy existing between eczema and catarrhal inflam- 



173 



mation of the mucous surface, in which as a consequence of the 
impression made by some irritant, generally cold, upon the part, 
serous effusion into the fibro-cellular mucous membrane with 
free outpouring of the 



fluid, distension of 



Fig. 16. 




Cell infiltration around separate fat cells of 
panni cuius adiposus in chronic eczema. 



the upper layer of the 
mucous membrane (an- 
swering to vesiculation), 
shedding of the epidermis, 
and the formation of more 
or less pus in the dis- 
charged fluid, with subse- 
quently chronic inflamma- 
tory thickening in its 
various degrees take place, 
must, I imagine, strike the 
reader very forcibly : and if 
he will recollect the pecu- 
liar cell changes and the 
general concomitants of 

eczema, he will at once see that it is impossible to include with it 
such diseases as pityriasis rubra, lichen, &c, as some do. 

In reviewing the morbid anatomy of eczema, one or two interest- 
ing and pertinent questions arise in this place. For instance, it 
is important to know what relation exists between the capillary 
congestion and the cell proliferation. Is the vascular alteration 
the consequence of cell activity — that is, is it the response to a 
hyperactivity of the cell elements, which acts, if I may so say, as 
a vis a fronts f Or is it the reverse % — is the cell proliferation the 
result of an increased supply of nutrient fluid sent to or retained 
in the part % for according to Neumann's experiments there is 
stasis in the vessels as one of the early phenomena. I am much 
inclined to think that in eczema both cells and vessels play an im- 
portant and somewhat independent part in obedience to a nerve- 
paresis. Mere capillary excitement does not give rise to serous 
exudation, cell proliferation and migration, escape of blood cells, as 
seen in eczema. If that were the case, erythemata would be observed 
overstepping their present limits, and where there is actual stasis 
in the vessels, as in psoriasis, all the sequences of eczema ought to 
occur. Mere capillary changes are unaccompanied by special 
cell changes ; but these latter involve the former. A priori, one 
is led to believe that there is some cause at work which directly 
stimulates the cell proliferation in eczema, and that the direction 
which this takes towards pus formation on the one hand, or fibril- 
lation on the other, depends upon the general nutritive tendencies 
of the person attacked. The active cell proliferation may imply 
and induce capillary excitement ; but it seems that the two things 
are coincident, for they arise, apparently, simultaneously. Now 



174 CATARRHAL INFLAMMATION, OR ECZEMA. 

what can account for this duplicate condition ? I think an altera- 
tion in the innervation of the part attacked. Looking to the 
general mode in which eczema is induced, to its history, and to 
the researches which have recently been published by Heidenhaim, 
Pniiger, Eckhard, and others, as to, the influence of nerve irritation 
in the production of tissue changes, I am quite disposed to agree 
with Hebra that in eczema " it is faulty innervation which is the 
most important element in its production " (vol. ii. p. 140). At 
any rate these things show the influence of nerve upon tissue. 
Hebra, however, believes that perverted innervation is the prime 
cause of eczema, by its leading " to congestion and other dis- 
turbances of the circulation," and he does not refer to the influence 
of nerve irritation in directly inducing cell proliferation. This 
latter is, I think, a necessary point to be admitted in explaining 
eczema. 

My experience has led me to conclude that eczematous subjects, 
as the rule, are thin, pale, and ill-nourished. Their skins are 
irritable and dry. They possess little, often no, subcutaneous fat ; 
and mal-assimilation, exposure, over-work, anxiety, and other 
influences which induce a lowering of tone, have operated upon 
them. An impressionable condition of the nervous system, or a 
lowering of nerve tone, is an essential condition in the evolution 
of eczema, it seems to me. I conclude, therefore, that, as faulty 
innervation is at the bottom of eczema, the existence of a dartrous 
or eczematous diathesis is not only unnecessary but unproven. 

Exciting Causes and Modifying Influences. — Admitting such a 
condition as that described — viz., nerve-originated-disorder in vessels 
and tissues, to be at the bottom of eczema : it is easy to appreciate the 
action of one group of exciting causes that play a prominent part 
in the evolution of the disease, and cause what are termed 
idiopathic eczemas. Reference is made to local irritants of a chemi- 
cal or mechanical nature ; to the action of heat, cold, and water ; 
the influence of occupation, in which the skin is stimulated by the 
blaze of the forge, the handling of sugar, flour, lime, or the like ; 
and to the excitation of the surface by scratching, as in scabies, 
prurigo. All or any of these may be in operation in a certain 
number of cases, even in some intensity, and yet no ill results 
will follow in the healthy — at least in the shape of eczema; 
whereas in other instances — the eczematously disposed — where they 
are by no means active, eczema readily shows itself. But there is 
a class of so-called causes that act from within the body upon 
the skin, comprising changes in the solids and fluids of the body, 
that rise to symptomatic eczema, as it is termed. And here we 
are brought at once face to face with the influence of constitu- 
tional conditions in skin diseases. Leaving out of consideration 
for the present the case of hereditary disease, I venture to think 
that though there is no special blood-state upon which the local 
manifestation of eczema depends, yet that alterations in the nutri- 



CATARRHAL INFLAMMATION, OR ECZEMA. 175 

tion at large may act in helping ont the development of, or in 
modifying eczema. 

In the first place, generally debility is often an accompaniment of 
the disease. In such case the resistant power or tone of the body 
generally is lowered ; and it is needless to argue that, under these 
circumstances, local irritants will do their work easily and effec- 
tually. A thorough chilling of the surface will induce an attack 
of eczema as much as that of bronchitis. 

Secondly, all disorders which are connected with retention of 
excreta in the system, and their circulation throughout the blood- 
current, may furnish the exciting cause of eczehia. This is a 
clinical fact of very great importance. Given the tendency to 
eczema, then the transmission of uric acid through the capillaries 
of the skin will so far derange as to aggravate certainly, and now 
and again excite, an eczematous eruption. This is what is meant 
by gouty eczema ; and by securing the absence of the uric acid 
from the circulation, the eczema will often disappear, and always 
be more amenable to treatment. The passage of uric acid through 
the cutaneous capillaries of an eczematous subject acts as much 
the part of an irritant as do some externals. A gouty state of 
blood may, therefore, excite and modify eczema. Such cases as I 
now refer to sometimes exist off and on for years, and are satu- 
rated with arsenic and mercurials, but w T hich are only relieved by 
recognising the complicating item of the free production and cir- 
culation of uric acid, and by instituting a regime calculated to 
arrest the continuance of those conditions. 

Another instance in which the retention of excreta may be 
observed aggravating, and it would even seem occasionally ex- 
citing, eczema, is in the case of those beyond midlife affected 
with eczema of the legs. In some of these cases there is, and 
has been for some time, deficient kidney action, and if a careful 
analysis of the urine be made, a deficiency in excretion will be 
observed. In other instances, I am quite aware that an excess of 
urea may be detected in the urine ; but the latter is scanty, and 
it is doubtful if the total solids got rid of are in excess of that of 
health. At least, that particular treatment which is successful in 
the cases named seems fully to confirm the truth of the proposi- 
tion that retention of excreta may influence eczema. But in some 
of these instances the presence of effete products, and even their 
excess in the urine, may be explained by the torpid action of the 
skin. Dryness of the skin is one of the features of tne eczematous 
habit ; and an inactive cutaneous surface now and again is one 
element in the evolution of eczema, no doubt by the influence it 
has in leading to the impurification of the blood-current; and 
where the kidneys at the same time fail to work perhaps as well 
as usual, the consequence must be the retention of waste products 
to a large extent. 

It is scarcely necessary to speak of the connexion between 



176 

eczema and the circulation of bile-products, because the same line 
of argument as that already used holds good in this case. The 
passage of bile through the skin in a predisposed subject may 
certainly excite eczema. It must also be remembered that the 
presence of morbid products in the blood tends to retard the or- 
dinary process of repair, so that the chronicity of a disease may 
well be explained in part by the conditions just now enumerated 
as dependent upon hepatic or renal derangement. 

Dyspepsia influences eczema much. In dyspeptic subjects ec- 
zemas are very obstinate ; inasmuch as such patients are weak 
and debilitated from mal-assimilation. 

A certain relationship exists between eczema and the strumous 
diathesis, the latter leading essentially to a modification of the 
typical disease. I suppose it to be quite unnecessary to adduce 
facts and figures in proof of the presence of the strumous dia- 
thesis in a goodly number of those who are attacked by eczema, 
especially in the case of the young, and still more to show that 
the particular form of the disease which is seen under such circum- 
stances is what is called eczema impetiginodes. Now the leading 
peculiarity of this variety is the tendency there is to the forma- 
tion of pus, and that from the outset of the disease ; and this not 
from the intensity of the inflammatory action, for the pus forma- 
tion is not in direct ratio to the severity of the local disease. If 
anything is to be accepted in medicine, it is certainly the existence 
of a pyogenic habit in those who are strumous. What more is 
to be expected than that, when eczema is set up in the strumous, 
and cell-proliferation commences, the tendency to the formation 
of pus, so strong, should operate upon the changes that ordinarily 
go on, so that a modification of the usual cell-growth results? 
The eczema is present, but it is impressed by the peculiar nutritive 
tendency of the individual whom it attacks. And not only is this 
influence of the strumous diathesis observed in young people, but 
now and then — I am inclined almost to say not uncommonly — in 
those of mature and even old age. One would imagine, from the 
little recognition of the strumous diathesis in persons of advanced 
age, that it wears itself out, or is non-existent and non-operative 
after a certain time of life. I venture to think this is a very 
grave mistake. True is it that those special declensions from 
health, and that general aspect of face and form which are com- 
monly accepted as characteristic of the strumous diathesis, are not 
observed in the aged ; but there are not wanting the evidences of 
their past occurrence, whilst the tendency ■ to pus formation, to 
unhealthy ulceration, and indolent repair, in connexion with that 
particular kind of treatment which acts most effectually, points to 
the operation of an old strumous taint as best explaining the 
modification of eczema which is observed. The nature oi. that 
modification is well expressed by the tendency just mentioned to 
suppuration, ulceration, and indolent repair. 



CATARRHAL INFLAMMATION, OR ECZEMA. 177 

I have thus far, then, concluded that eczema is not dependent 
upon the existence of a crasis or diathesis in the general sense of 
those terras, but upon an impressionable condition of the nervous 
system, in which the control of the latter over the nutrition of the 
skin is somewhat lessened ; that external irritants, acting locally 
or generally; and internal agencies, such as the circulation of 
waste and effete products, may excite eruptive phenomena ; and 
that the changes in the cell elements may be modified to some 
extent by the special nutritive proclivities of the individual. 
Theoretically, where external exciting causes are at work, and the 
eczematous tendency is not marked, the eruption will be localized ; 
but it may be symmetrical where the exciting cause operates on 
symmetrical parts, as in the case of eczema, of the hands in bakers 
and washerwomen ; or when it act generally on the surface, as in 
the case of cold. Where, on the other hand, the immediate ex- 
citant of eczema is an internal cause, then the eczema is more or 
less general, and it is in these cases that the inflammatory and 
impetiginous forms are usually met with. 

The history of infantile eczema might seem at first sight to 
stand in antagonism to these propositions ; but, on calling to 
mind the concomitants of infantile eczema, it will be found en- 
tirely to confirm their truth. The tissues of the skin in the 
young, in the first place, are rapidly and readily irritated ; slight 
friction, cold, or heat induces mischief, which is unaccounted for 
save on the supposition that there is a great tendency to inflam- 
matory changes, involving disturbance 01 the circulation and cell- 
life of the tissues, incidental to infancy. A bronchitis is as readily 
evoked as an eczema. So that the skin is not alone peculiarly 
sensitive. And if it is possible to easily excite extensive changes 
in a mucous surface without the presence of any diathesis, it 
seems indeed strange that it should be supposed that analogous 
results may not follow in the case of the skin under similar cir- 
cumstances. Then, secondly, infantile eczema is observed in 
lymphatic and often markedly strumous temperaments ; in the 
ill -fed ; in the hereditarily eczematous ; in the uncleanly, and 
those who are otherwise badly hygiened ; in the children of weak 
parents ; in those who exhibit mal -assimilation, evidenced too 
plainly in the pale stools, the dyspepsia, the passage of food in a 
more or less undigested state, and the imperfect absorption of all 
fatty matter ; after exposure to cold ; in connection with debility 
consequent upon the occurrence of acute febrile disease ; after 
the disturbance of the system produced by vaccination ; in con- 
nexion with teething, and so on. Now here is a catalogue of con- 
comitants that lead to the perverted innervation to which Hebra 
refers. What room is left for the operation of a special diathetic 
condition % What need is there to suppose its existence % I see 
none whatever. 1 think we are apt to judge of the existence of 
a special diathesis in infantile eczema because the strumous dia- 
12 



178 

thesis is often present in the disease, but it acts only as a modifying 
agency. There exists undoubted facts which go to prove that 
eczema may directly originate in the skin without there being a 
specially related blood-change as a cause, and yet be modified by 
diathetic conditions. The occurrence of an eczema without there 
being a diathesis, in the ordinary sense of that word, is not more 
difficult to comprehend than is that of an extensive bronchitis or 
mu co-enteritis. 

I may make one or two remarks as to " syphilitic" eczema in in- 
fants. There are certain instances of pretty general and obstinate 
eczema in young children, in which there is not much discharge, 
not much crusting, but swelling, more or less induration and 
scaliness, sometimes dark scabs, accompanied by a dirty or actually 
pigmented state of skin, and often what looks like a pityriasis, with 
slight puckering about the corners of the mouth. Now and then 
there are patches of eczema nummulare about the belly, and co- 
incident intestinal irritation, but apparently nothing else. These 
cases do not improve under the usual treatment for infantile 
eczema. They get well under anti-syphilitic treatment — at least 
the use of mercurials. There is often a history of syphilis to be 
found in the parents. The cases referred to do not arise out of a 
regular attack of congenital syphilis. Now, the fact that the 
bichloride of mercury cures them is not positive proof of their 
syphilitic nature, for it may be that, as in chronic eczema with 
induration, the remedy controls and alters the tissue changes. I 
look upon these as instances, not of syphilitic eczema, but of 
eczema occurring in and modified by the syphilitic diathesis. 

It may be well to make particular reference to the influence of 
teething in eczema. I find Plebra saying that "great abuse is 
made of the teething of children, as of their temperaments ; and 
just as every cough, colic, fever, diarrhoea, cramp, or fit in an 
infant is put down to teething, so eczema is ascribed to the same 
cause when it occurs at this period. And although," he continues, 
" I by no means ignore the influence which this physiological 
process is capable of exerting upon the whole of the organs and 
functions of an infant, yet I cannot admit it to be a cause of 
eczema." 

What Hebra says is true, but it falls short of proving that teething 
never excites or influences eczema. Connected as the process of 
dentition is with febrile and gastric disturbances, with irritation 
of the nervous system, and capable as it is by reflex action of in- 
fluencing almost any part of the body, I cannot see how it can be 
otherwise than that now and again the skin should be disturbed by 
it. The coincidence of irregular dentition with infantile eczema, 
the rectification of derangements of the former with subsidence of 
the latter, and such-like relationships, seem to show that if teeth- 
ing be not a real cause, yet it may be an excitant of eczema. 

So far I have said nothing of hereditary influence in the genesis 



CATARRHAL INFLAMMATION, OR ECZEMA. 179 

of eczema. This is perhaps the most opportune moment to refer to 
it. Is eczema ever hereditary? It is quite certain that ecze^ 
matous subjects do not necessarily transmit the disease, however 
marked it may be in their case. Further, having regard to the great 
frequency of eczema, it is certainly comparatively uncommon to 
meet with cases in which that disease seems to be hereditarily 
transmitted. On the other hand, there are occasions when the 
prevailing disease tendency, in several or all the members of a 
family, is to the development of eczema, and at an early age, too ; 
this tendency being apparently best accounted for by the suppo- 
sition of an hereditary bias. Hebra remarks that the fact that in 
a few cases whole families may be found affected, must be viewed 
as exceptional when contrasted with the general results of expe- 
rience. This is true enough, but I do not agree that it can only 
prove at the utmost that eczema in parents does not exclude its 
occurrence in their children. Of course it is in infantile eczema 
that observers are wont specially to recognise hereditary influ- 
ence ; but the conditions that concur to alter the nutrition of the 
child's skin, to which I have referred, if due allowance be made 
for their influence, leave scant room for the operation of any here- 
ditary transmission in the majoritj r of cases, equally with that of a 
peculiar blood state. But, on the whole, I do not think that, as 
far as clinical observation goes at present, one can refuse, especially 
in cases where two or three or more members of a family are 
affected by eczema, and there is a history of the same disease in 
the parents, to allow that father or mother may have really handed 
down the affection to son or daughter. What seems to me of im- 
portance to state is this — that, in order that eczema may be here- 
ditarily transmitted to an offspring, it is not needful that there 
exist in the parent an eczematous diathesis in the ordinary sense 
of that term. If peculiarities of local form and aspect can be 
handed down, why may not dispositions to abnormal nutrition 
localized in one organ or tissue of the parent be repeated in the 
child ? If heart disease runs in a family, why may not skin diseases 
do likewise ? If xeroderma, and its more advanced stage, ichthy- 
osis, which are certainly not blood diseases, be hereditary — and 
they unquestionably are so — why may not eczema behave in a 
similar manner without it being a blood disease ? Admitting, 
therefore, the occasional hereditary transmission of eczema, I find 
in that event no ground for supposing that there is a special ecze- 
matous crasis or diathesis. 

I have now analysed the disease under consideration in its sup- 
posed dependence upon constitutional conditions. Now I turn to 
notice the relation which subsists between eczema and other coin- 
cident local diseases, often affecting important internal organs. 
Bronchitis of a sub-acute kind is not an unusual coincidence, as is 
the case of many other diseases, but it may sometimes have special 
relation to the eczema. I have had under my care recently at 



180 CATARRHAL INFLAMMATION, OR ECZEMA. 

University College Hospital, a couple of interesting instances of 
the kind, in two children three and four years old, the subjects of 
general and chronic eczema, modified by the strumous diathesis : 
and in whom eczema has existed off and on since the age of a few 
months. Exposure to cold is almost sure to bring out the eruption 
afresh in the skin, if the children are not in what is regarded by 
the parents as " good health." Not many days since I missed one 
of these patients, and found that the child had caught cold and 
become attacked by bronchitis, there being a large amount of 
expectoration. The skin during the attack, the mother remarked, 
got nearly well as regards the discharge and crusting : and this has 
been the case on several occasions. The brothers were very liable 
when young, the mother remarks, to bronchitis and eruptions also. 
I have seen a similar relation established between the skin and 
mucous surface of the intestinal tract. 

In such cases as these the vicarious relation between the affec- 
tion of the skin and mucous surface has led to the use by some 
writers of the term " substitutive " as applied to the eczema. 
There is no difficulty in understanding that, when active disease is 
going on in the mucous membrane, the skin will be quiescent, and 
vice versa. One would be inclined to recognise in these instances 
the necessity for a specially tonic plan of treatment, and to question 
the value of arsenic or any other agent that can in any way irritate 
the mucous surfaces. Save the fact that there seems in these cases 
a general disposition to irritability of the tissues — and there is 
every analogy between eczema and catarrh of the mucous surface 
— there does not seem to be much more of clinical interest in 
these cases, so far as the question of etiology is concerned. Authors 
have described the occurrence of bronchial asthma in connexion 
with eczema, but the remarks just made touching sub-acute 
bronchitis may be held to apply generally to asthma, which is de- 
pendent upon the changes occurring in the air-passages during 
the bronchitis itself. Another affection of a mucous membrane — 
viz., leucorrhcea — seems to bear occasionally the same relation to 
eczema as does bronchitis or intestinal catarrh — that is to say, it 
is " substitutive ; " and I think I have seen something of the same 
kind in connexion with the urinary passages. Now, in none of 
these cases is there any such thing, I take it, as metastasis in the 
strict sense of that term. The disappearance of an eczema from 
the skin, in connexion with the development of a bronchitis, is a 
consequence and not a cause, of the latter, which is evoked by its 
special excitant, cold or what not. One finds, of course, the affection 
of the mucous surface frequently absent in the severest cases of 
eczema, and vice versa / but the occasional substitution of the one 
for the other, and the peculiar nature of the coincidence referred 
to, do certainly convey to my mind — that is, taking the whole 
history of these cases into consideration — the impression of the 
close analogy which subsists between " catarrhal " inflammation 



CATARRHAL INFLAMMATION, OR ECZEMA. 181 

of the mucous membranes — in which the free secretion is the 
marked feature — and eczema ; and it is open to proof that the two 
originate under similar conditions, and admit of the same essential 
treatment. Dyspepsia is a common companion, too, of eczema, 
and it may be^ in some sense substitutive, but not markedly or 
frequently so. It leads, when present, to debility, of course, and 
to imperfect excretion necessarily — two conditions eminently 
favorable to the occurrence of eczema. 

The influence of renal disease on eczema has been referred to. 
Anything which, in those disposed to eczema, throws additional 
work upon the skin may help out the disease, especially if the 
renal excretion of nitrogenous matters is diminished, and excreta, 
together with watery fluid, are accumulating in the system. 

It has fallen to my lot to see several cases of eczema in con- 
nexion with heart-disease leading to dropsy, and, I think, helped 
out by the general derangement induced by the altered circulation. 
Such cases are greatly relieved by treating judiciously the cardiac 
mischief. 

It is necessary to say one word in regard to the part played by 
mental emotion in leading to attacks of eczema. Ilebra says that 
the connexion as cause and effect between disorders of the mind 
and mental emotions and eczema, which appears as an axiom in 
every book on the subject, is a mere fancy thrown out at random. 
I agree with him so far as to mental disturbances being true causes 
of eczema ; but, I think, in virtue of their depressing influence, 
when that is exercised upon the body generally, that they always 
leave individuals more open to the attack of eczema than if they 
were not in operation, and trouble, worry, and mental anxiety 
are often observed to aggravate the disease. 

Summary of Etiological Considerations. — I will try to gather up 
into a general statement the main propositions which have been 
submitted to the reader's consideration under the head of Etiology. 
It has been the rule to regard eczema as an inflammatory disease, 
and the expression of a diathesis, styled by the French the 
" dartrous diathesis " — a convenient term, as McCall Anderson 
says, to cloak our ignorance of its nature. The word " debility " has 
been used to characterize the constitutional condition upon which 
eczema is thought to depend. What is really meant is that the 
local changes in eczema are due to an altered state of the nutritive 
fluids of the body, and primarily of the blood. Now, I recognise 
the fact that eczema may be modified by diathesis, but that it is not 
essentially the result of any special alteration of the blood-current. 
And I look more particularly for the origin of eczema to the 
skin itself. It is clear that alteration of the blood, followed 
by hyperemia, is quite incapable of explaining the phenomena of 
the disease, and that changes originating in the cells of the derma 
and rete mucosum* have very much to do therewith. Modern 
research seems to point to an altered relation between the nerve 



182 DIAGNOSIS OF ECZEMA. 

force and the cell life as the starting-point, or the reason why 
eczema occurs ; for nerve irritation certainly can give rise to cell 
proliferation, and it seems clear that nerve-filaments ran to, and 
lose themselves in, the rete where the changes in eczema are the 
most marked. Well, given " perverted innervation,". as Hebra terms 
it, it is easy to understand that agencies, acting both externally and 
internally, may readily evoke — though not per se cause — eczema ; 
though eczema is modified by altered blood-states or constitutional 
tendencies, such as gout or struma. The influence of organic or 
functional diseases of important organs is a matter requiring to be 
more distinctly appreciated, in so far as these throw more work 
upon the skin, lead to debility, or the impurification of the blood- 
current. The mucous and cutaneous membranes exhibit, it would 
appear, a remarkable similarity in regard to the essential patho- 
logical changes that take place in catarrh, on the one hand, and 
eczema on the other; so much so as to lead one to suppose — 
allowing for difference of texture and accidental surroundings, 
such as heat, moisture, and exposure to the external air — that the 
two above mentioned are analogous affections. This is the more 
probable on a consideration of their now and then decidedly 
" substitutive " correlation. Speaking in broad terms, it may be 
said, moreover, that the cause of eczema is multiple ; it is perverted 
innervation as a sine qua non, but plus — not as causes, but part 
causes or excitants in a variety of combinations and varying fre- 
quency of co-existence — general debility, morbid blood-states, 
strumous diathesis, local irritation of the most diverse kinds, 
disease of important viscera, mental depression, and so on. This 
shows that the dermatologist must comprehend the nature of 
diseases in general ere he can treat eczema successfully. 

Diagnosis. — I hold, of course, that the main feature of eczema is 
the presence of a peculiar " discharge," which dries into thin 
yellow crusts. However long standing any case of eczema may 
be, it will always furnish sufficient evidence in its history of the 
fact of its being a moist disease. If attention be given to the 
point it will soon be discovered (what I have repeatedly insisted 
upon as an important clinical fact) that in the vast majority of 
cases the disease has existed a long time before it comes under 
the notice of the practitioner ; that the early stage is rarely seen, 
only in those cases in which the disease is general and severe and 
the constitutional affection is sufficiently grave to compel the 
patient to seek for medical advice at once. The vesicular stage 
consequently rarely comes under the eye of the physician. If the 
patient be closely taxed as to antecedents, he will often state that 
the disease began with redness, that then little bladders or 
watery heads formed, and the surface began to " weep " or 
" discharge." Where eczema is on the increase the vesiculation 
may frequently be detected at the edge of the patch. It is the 
"catarrhal" aspect of the disease which I regard as so " charac- 



DIAGNOSIS OF ECZEMA. 183 

teristic." There is as much difference between eczema and lichen 
as there is betwixt bronchitis and pneumonia; and there is this 
additional distinctive mark of eczema, that the application of 
irritants will mostly evoke " discharge ;" i.e. there is a capacity for 
discharge always present that is absent in other similar diseases. 
There are many diseases confounded with true eczema ; these vary 
according to the stage and " age " of the eczema. Acute general 
eczema may be mistaken in the first place for one of the acute 
specific diseases, in consequence of the pyrexia which is sometimes 
present. The redness, too, has a somewhat punctated appearance 
at its earliest stage, but very quickly all doubt vanishes by the 
fact that the eruption is clearly out of all proportion, as regards 
severity, with the pyrexia. The patient is not so ill as he or she 
would be if the case were one of zymotic nature, and as the vesicu- 
lation rapidly shows itself. Acute general lichen is accompanied 
by much itching. It affects particularly the outside of the limbs. 
Though the eruption is well developed and plentiful, it is truly 
papular, the papules feeling hard and dry, and there is no " dis- 
charge," and no crusting. The inflammation is decidedly plastic 
as distinguished from serous : and this applies to all cases of 
lichen. Again, the slighter forms of eczema may be mistaken for 
Ery theme vesiculeux of Hardy, which arises from the application 
of a local irritant, and is characterized by vesicles upon a red base. 
The latter disease is of short duration ; it has no tendency to spread, 
it is localized and the discharge is not viscid stiffening linen like 
that of eczema. Intertrigo is produced by an evident cause — 
the friction of two surfaces ; its seat is the folds of the skin in 
apposition, and it is marked also by absence of vesicles and crusts, 
no less than by the presence of a thin muciform secretion. 

No error should arise in diagnosing ordinary erythema, the 
negative evidence in regard to discharge and crusting sufficing. 
Erysipelas is an acute and severe disease, accompanied by shining, 
tense, smarting swelling, upon which are developed phlyctenge ; 
there are no pustules, vesicles, &c. The definite course of herpes 
with its small bullae collected together upon a red base, which do 
not burst, but shrivel away in a few days, with the absence- of light 
yellow crusts — should define the difference between it and eczema. 
In sudamina the vesicles are large, scattered over a large extent 
of surface, developing after sharp perspiration, generally in the 
course of acute p} T rexial disease, and drying up in a few days, 
with slight desquamation. Occasionally one sees, especially about 
the hands (the palms), a form of disease which appears to be an 
eczema, in which the fluid has collected beneath a tough layer -of 
skin, which is somewhat raised if the disease be left alone ; the 
skin peels off in a thickish layer, leaving behind a reddish more 
or less tender surface, which does not crust over but simply dries. 
If the disease be attentively examined at the outset, the fluid 
will be seen to be perfectly clear (not milky), and to be distending, 



184 DIAGNOSIS OF ECZEMA. 

as I believe, the perspiratory ducts, escaping thence beneath the 
upper layer of the cuticle. This is an idrosis, an acute outpouring of 
fluid by the sweat glands, accompanied by an inflammatory condi- 
tion, and as a consequence, death of the upper layer of the cutis. 
The disease is always classed with eczema. The treatment however 
is somewhat different. In scabies the vesicles are scattered, not con- 
fluent ; they are acuminated, and present the well-known furrow, 
at whose end the acarus lies imbedded and may be detected. There 
is no inflammatory base as a rule. Eczema may be interdigital, and 
then lead to confusion ; but in scabies the eruption is seated on the 
anterior surface of the forearm, about the breast, abdomen, the 
buttocks, and the penis ; on the feet, pustules (impetiginous and ec- 
thymatous) are present. The itching is intense at night, but relieved 
by scratching. In scabies, crusts contain acari. In its more chronic 
(the pustular, and scaly) stages, the confusion of eczema with other 
diseases is of frequent occurrence. Where the body generally is 
affected confusion may arise in the case of general psoriasis, 
pityriasis rubra, and pemphigus foliaeeus and lichen planus. 
The necessity for distinguishing between general eczema and 
psoriasis is great. The history of u discharge " in the eczema 
case is here the main guide. An eczema so severe as to cover 
nearly the whole body could not be without the " characteristic " 
discharge at the outset of its course. The scales are epithelial in 
psoriasis, and only partially so in eczema, in which disease the 
crusts are made up of blastema with granular cells, and pyoid 
corpuscles (inflammatory products). The disease in psoriasis, 
seen generally very clearly on the elbows and knees, or head, is an 
hypertrophy chiefly of the epithelial layer of the skin, the papillary 
portion being involved : wmereas eczema is an inflammatory and 
exudative affair, and moreover in psoriasis the disease affects the 
elbows and knees particularly, and consists of patches covered over 
by very silvery white scales. Nothing is more certain than this 
contrast. The origin of the disease in pemphigus foliaeeus is from 
bullae that first appear about the chest, and thence invade the 
general surface : they abort and are replaced by large scales and 
incrustations, the scales being often thick like parchment ; the 
skin is not infiltrated ; the disease is a general one. In pityriasis 
rubra the whole of the body is implicated, presenting a dry red 
glazed surface, with no infiltration of the skin, but the formation of 
scales that now take the form of branny flakes, now of large thin 
squamae easily detached ; more extensive plates may form. All 
kinds may be present in the same subject. In some cases there 
are patches of skin that remind one in the feel, of a piece of 
dried bladder, only that they are reddish. There is no discharge, 
merely redness, desquamation, and condensation, wuthout much 
itching, burning, or other uncomfortable symptom. 

When the eczema is not general but local, difficulties frequently 
arise. I include impetigo under the term eczema, save in the 
case of the contagious impetigo, which in its "sparse" and 



TREATMENT OF ECZEMA. 185 

" contagious " nature cannot but be recognised. The inflamma- 
tory form, eczema rubrum, attacks several regions at once ; the 
rigors, smarting, and pyrexia may make one suspect sometimes 
the advent of erysipelas. When eczema attacks the hand, bullae 
may form in consequence of the coalescence of vesicles, and 
pemphigus may seem to be present, but the occurrence of the 
vesicles or crusts elsewhere in eczema, and of bullae in pemphigus, 
will suffice to avoid error. Tinea circinata (when well marked) I 
have seen more than once mistaken for eczema, but the red base 
with minute vesicles upon it when they are present, and the pecu- 
liarly well-defined and perfectly circular shape of the patch in the 
early stage, and the delicately scaly or " frayed " aspect of the 
tinea — the scales being formed not so much by discharge as by epi- 
thelial scales, which are readily recognised under the microscope — 
and the detection of a fungus, should settle the diagnosis. There 
are several phases of tinea generally regarded as eczema, and I 
refer the reader to the section on tinea circinata for fuller informa- 
tion on this point. Seborrhcea sicca or squamosa, and even se- 
borrhcea oleosa, are mistaken, I believe, generally for eczema. 
There is in ordinary seborrhcea no " discharge ; " there is a red 
surface which becomes covered over with little dirty yellow flat 
crusts, which are made up of fatty and epithelial matters, and on 
these being picked off, which may be done pretty readily, the sur- 
face beneath is seen to be red, dry, and somewhat glazy, the seba- 
ceous follicles, moreover, being somewhat distended and prominent. 
In other cases the sebaceous flux may be of a more oily nature, 
and then there is less crusting. There is a discharge, but it is 
fatty, and there is not the crusting of eczema, whilst the sebaceous 
glands often atrophy somewhat. But this form of seborrhcea may 
take on the aspect of eczema faciei, the naked-eye difference be- 
tween the two being the peculiar oily, honey-like character of 
the discharge in seborrhcea, and the absence of " crusting " 
which one would expect, having regard to the amount of discharge, 
were it eczema. 

From eczema, favus and tinea would be known at once by 
the microscopic characters of the scales and hairs. 

Lastly, eczema may complicate and occur together with other 
diseases : with lichen, scabies, or even psoriasis, &v. : and in such 
instances there is necessarily a blending together of the characters 
of the separate diseases. To remember the possible co- existence 
of diseases is one of the first necessities to a safe diagnosis. 

Treatment. — I now come to the important question of the 
treatment of eczema in its different forms : — 

General Considerations. — Firstly : It is important to remember 
that a typical case of well-marked eczema has certain stages through 
which it must pass more or less rapidly in its progress towards 
cure — viz., erythema, vesiculation, ichoration, pustulation, and 
squamation. Now in the earlier stages the object should be to 
moderate inflammatory action — I use this term as a convenient 



186 TREATMENT OF ECZEMA. 

one for the vascular and cell changes ; and in the latter, especially 
that of squamation, to rouse the skin to a healthy action, so that 
those changes which are comprehended in the words " chronic 
inflammat'on " may be prevented occurring. The treatment is, 
as the rule, essentially palliative in the earlier, and curative in the 
squamous stages ; or first soothing, and then stimulating. 

Secondly. — Under certain conditions, however, the practitioner 
may really hope to cut short or to abort an eczema. This can be 
effected only in the slighter forms of the disease, and more par- 
ticularly those excited by local irritants ; or by the employment of 
treatment at the very earliest moment. In instances of eczema 
connected with internal disorder it is difficult and uncommon to 
prevent the disease running through its ordinary stages. It should 
be our desire to conduct the disease through and past its discharge 
phase towards that of squamation. 

Thirdly. — It is requisite to distinguish between what is essential 
and what is accidental in eczema. The capillary dilatation, the 
cell changes, and the escape of fluid giving rise to vesiculation, and 
so on, with the disturbance of the epithelial formation, all depen- 
dent originally upon perverted innervation, constitute the essen- 
tials ; the strumous and gouty diatheses, organic diseases of in- 
ternal organs, and the consequences of chronic congestion, &c, 
form the accidentals, which in some instances powerfully influ- 
ence the real disease. 

Fourthly. — Inasmuch as perverted innervation plays an impor- 
tant part in the genesis of eczema, and as cell prolif ei ation can be 
induced by nerve irritation, the main treatment of eczema must 
be of a soothing nature, especially as regards local treatment in 
the early stages. 

Fifthly. — There is no specific for eczema. That is to say, eczema 
does not depend upon a special blood-state which is alterable by 
the use of any particular drug ; for that is the idea which prompts 
the employment of specifics for eczema. 

Sixthly. — It would seem that there is no better term than debility 
(pure and simple) by which to describe the general condition 
which is most intimately connected with the evolution of uncom- 
plicated eczema. 

Eczema then is a curable disease, running, as the rule, through 
certain definite stages — the passage through which should be pro- 
moted ; aggravated by anything that " irritates " the skin itself, 
from within or without ; occasionally relieved, or even aborted, in 
its slighter forms or earliest stages, by soothing remedies ; liable 
to be complicated by accidental occurrences consequent upon the 
persistence of congestion, such as oedema, induration, atrophy, 
ifec. : modified by constitutional conditions, especially gout, struma, 
and syphilis ; influenced by organic diseases of vital organs — the 
liver, the kidneys, the heart, the stomach ; associated always with 
a lowering of the general vitality of the system, and not cured by 



TREATMENT OF ECZEMA. 187 

any " specific." I venture to lay emphatic stress on two of these 
points — viz., the modification of eczema by different constitutional 
conditions, and the necessity for adopting a soothing plan of treat- 
ment always in the earlier stages of the disease. 

It is impossible for me to deal with my subject in such a way 
as to meet the necessities and peculiarities of every case that may 
present itself to the practitioner, so varied are the complications 
'and concomitants of eczema. I can only deal with general cases. 
I assume that in all instances the practitioner starts by correcting 
any deficient action of the emunctory organs; that constipation, 
hepatic torpor, or congestion, dyspepsia, deficient renal excretion, 
or inactivity of the skin as a whole, be remedied. It is the more 
necessary to attend to these matters in eczema, because the general 
debility involves in many instances a more or less sluggish action 
of the excretory organs, and this, by loading the blood-current with 
effete products, does tend to retard the reparative process, if not 
to aggravate the eczema. The careful examination of the urine 
at the outset often reveals the existence of conditions that at once 
put one on the right track as regards treatment. Deficiency or 
excess of urea, the presence of uric acid or phosphatic deposits in 
large amount, or oxalates, may be detected under different circum- 
stances, and point to the brain or liver as in error, whichever 
the case may be. 

There appear to me to be three questions which every practi- 
tioner should ask himself when a case of eczema falls into his 
hands for treatment — Of what variety is it ? ' At what stage is it ? 
and What are its complications ? 

First, as to variety. It is here that Willan's division of eczema 
becomes so satisfactory. Though, as I have already stated, there 
are no hard-and-fast lines between the simple, the inflammatory, 
and impetiginous varieties of eczema, yet they are broadly dis- 
tinguishable in the general run of cases. 

Secondly, as to stage. If the skin of an eczematous subject be 
essentially irritable, as I believe, then, whenever and as long as 
any local inflammation is present, or there is pain, must one soothe. 
At the very outset of an eczema sedatives may much abate, though 
rarely stay the progress of the disease. This happens in cases of 
eczema simplex ; but as a rule cases run on to the discharge stage. 
I hold most resolutely that until that stage is passed, and squama- 
tion is reached, nothing in the form of a stimulant or irritant 
should be applied to an eczema. Hence the consideration of the 
stage of an eczema, in my eyes, has a most important significance. 
When the stage of squamation has finally set in, the disease may 
be termed chronic, and I then stimulate. Until that is reached, 
however, the disease should always be regarded as acute, and be 
soothed. Perhaps this is the lesson of all others to teach in the 
present attitude of dermatologists in their treatment of eczema. 
Further, when the stage of squamation has lasted some time, as 



188 TREATMENT OF ECZEMA SIMPLEX. 

before observed, one may have to treat chronic inflammatory 
thickening rather than eczema. 

Lastly, as to complications. The very last condition referred to 
is one of them; the others are chiefly general conditions of a 
diathetic nature, or functional or organic disease of important 
organs, and these I shall note in detail in speaking of general 
treatment. 

But I may appear to have said too little in a general way of the 
internal treatment in relation to variety and stage ; I hasten to 
add, therefore, that it follows from what has been said that 
there is one general rule applicable to all cases of eczema, and that 
is, that one should attempt to conduct all cases of this disease to 
the scaly stage as soon as possible. To moderate excessive tissue- 
change in the skin, and allay the nerve irritation by general re- 
medies in the early stage, is to aid in this object. But in eczema 
simplex no general treatment is requisite, save aperients and 
simple tonics. In eczema rubrum : dyspepsia, gouty tendencies, 
and the circulation of effete products in the blood must be re- 
medied. But in the case of eczema impetiginodes, the pus-forma- 
tion is not an evidence of intensity of inflammation, but of a pyo- 
genic habit of body ; and whilst. I meet eczema rubrum associated 
w T ith free pus-formation by salines, aperients, and the like, in 
the earliest stages, I at once, and from the outset, have recourse 
to cod-liver oil, iodine, iron, and the like, in the impetiginous 
variety, for these alone control the free formation of pus. I 
learnt this perhaps empirically, but I now see very clearly its 
reasonableness. It will be noticed how Willan's division of eczema 
helps in this matter. 

ECZEMA SIMPLEX. 

Iii entering upon details I shall speak of the acute stages first, 
and leave chronic eczema to be specially dealt with by-and-by. 
Let me first get rid of the treatment of eczema simplex : such as is 
produced by the action of external irritants — e.g., heat, sand, flour, 
water, soda (as in washing), arnica, sulphur, &c. Here the disease 
is localized, and the treatment is practically local also. The fami- 
liar instance of the eczema induced in washerwomen and house- 
wives who do much washing, by the action of soda, may serve as a 
type of this variety. It is true that the attacked are often debili- 
tated and are therefore benefited by tonics, but, as the rule, the 
exclusion of air from the part, its removal from the influence of 
the irritant, and the application of some soothing or astringent 
remedy, cure the cases. The use of a lotion, perhaps, is preferable in 
the daytime, and it is best to apply the following: — An ounce of very 
finely levigated calamine powder, with two drachms of glycerine, 
half an ounce of oxide of zinc, and six ounces of water. This may 
be applied, after being well shaken up, by means of a sponge or 
camel's hair pencil, frequently (five or six times during the day), 



TREATMENT OF ECZEMA EUBRUM. 189 

the powder being allowed to dry on. The air is in a great degree 
excluded by the powdery layer left upon the skin. I object to the 
ordinary calamine powder of the shops on account of the coarse- 
ness of its particles and its red colour. If there be ranch, swelling, 
I prefer to use, in addition, some of the lead ointment of the old 
London Pharmacopoeia or litharge ointment, thinly spread on rag, 
and closely applied at night, and kept on with a few turns of a 
bandage. (See Formulae, No. 121.) If at the outset of the disease 
there be much pain, then poppy fomentations may be used before 
the ointment, and the first application of the lotion in the 
morning. An aperient or two, with the dilute mineral acids and 
bitters as a tonic internally, and some tarry preparation locally at 
the fag end of the attack, suffice to complete all that is needed for 
the treatment of eczema simplex. 

No better opportunity will be afforded me to say that no powder 
of any kind should be used to the skin of an eczematous subject 
if it be gritty, or if its particles be large. Special care should be 
taken to use perfectly neutral ointments. The lead ointment I 
spoke of should be made fresh every few days. The benzoated 
zinc ointment is advantageous on account of its non-rancid 
qualities, for I am confident a great deal of harm is clone by applying 
rancid unguents to the eruption of eczema. On the whole, oint- 
ments are best suited to the scaly, and lotions to the acute and 
discharging stages. 

ECZEMA EUBRUM. 

I now turn to the next clinical variety of eczema — eczema 
rubrum — in its acuter stages. There is a certain number of cases 
which seem to locate themselves on the border-land between this 
variety and eczema simplex. A typical case may be given as 
follows : — A man (or woman), aged forty or so, presents himself 
before the practitioner, and states that he is attacked by an 
eruption on the head and neck, which gives off a good deal of 
scurf. On inspection an eczema in the squamous stage is noticed, 
affecting the whole scalp, accompanied by a good deal of irritation 
and some slight redness. The eczema may extend down the neck, 
and there may be patches of the same kind about the arm, or the 
leg, or the thigh, and sometimes the trunk. The history does not 
give evidence that any marked inflammatory state has preceded, 
though the patient says the parts attacked were hot and red, and 
discharged before the scales formed. The only thing about the 
general health is debility. The patient has had an anxious time 
in regard to his duties or his family ; has worked hard and has 
lived fairly ; but somehow or other has lost tone and flesh. He is 
not up to his usual mark. He looks pale, languid, thin ; and his 
assimilation is bad. JSTow alkaline baths, cod-liver oil, and the 
• mineral acids, with tonics, ex. quinine, or, if there be much atonic 
dyspepsia and itching, strychnine : and, locally, the calamine lotion, 



190 TREATMENT OF ECZEMA RUBRUM. 

and presently a weak tarry (oil of cade) unguent, or a mild mercu- 
rial ointment, have never failed in my hands to cure. But the mass 
of cases falling under this head are more inflammatory, and con- 
nected with definite derangements of the general system. Mistake 
is often made in applying the term eczema rubrum to an eczema 
which attacks the bends of the joints only. It should be appro- 
priated to the disease according to its inflammatory character, and 
not its seat. It is at the same time true that eczema rubrum very 
frequently involves the flexures of the joints. 

General Treatment. — I will suppose, however, that the practi- 
tioner has a well-marked case of eczema rubrum to treat, and I will 
speak of general remedies first of all. I am in the habit of teaching 
that he should search for one or more of the following conditions : — 
(1) an hereditary tendency ; (2) the strumous diathesis and bad 
feeding in young life (well marked), and strumous taints (less 
marked), in the old; (3) simple debility; (4) chronic dyspepsia; 
(5) gout; (6) nervous depression connected with mental excite- 
ment; (7) deficient kidney-action, especially in old persons; (8) 
organic disease of the heart in the aged. The treatment must be 
adapted to meet all these conditions. 

(1). Is the disease hereditary \ Then a very carefully arranged 
plan of treatment, dietetic, hygienic, and medicinal, is needed ; for 
here the eczema has a profound hold on the system. 

(2). The strumous habit must be combated wherever it is met 
with ; and, happily, success is certain if cod-liver oil, steel wine, 
and the like are persevered with. I will only acid here, that 
wherever I find an eczema in old people in which the pus-forma- 
tion is altogether out of relation to the degree of local inflammatory 
action, I am very careful to seek for a history of struma ; and 
even in the oldest persons anti-strumous remedies greatly aid in 
the cure of the disease— at least I find it so. Senile struma is an 
important state to recognise. 

(3), Simple debility is very frequently all that can be detected, 
even in those instances in which the disease is extensive and severe. 
It may be advisable, even under these circumstances, if there be 
much local heat, burning, or smarting, to commence with saline 
aperients, or even small doses of antimony with ammonia; but 
I speedily one should have recourse to tonics. I know none better 
than the mineral acids with bark, or acids and iron, with aperients 
if need be (see Formula 159) ; but it is necessary, in order to get 
the full benefit of the acid, to increase the dose — say, of the dilute 
nitric acid, to thirty or forty drops in the dose. At the same time, 
cod-liver oil is even more useful in thin and spare subjects. Rest 
from over-work of body and mind, change of scene, good food, and 
a paucity of stimulants, are also most beneficial in these cases. 

(4). Chronic dyspepsia is very frequently present as an aggravant 
of eczema, and it requires all the tact of the physician to remedy 
it. It is in these cases that alkalies occasionally do much good in 



TREATMENT OF ECZEMA KUBKUM. 191 

connexion with bismuth, small doses of strychnine, iron, ferru- 
ginous waters, or the mineral acids, as the case may be. But the 
patient must also be carefully dieted. In those of good position 
the diet must be simplified, the plainest meats be taken, and 
stimulants avoided. 

(5). Eczema often occurs in gouty subjects, and needs a good 
deal of care, for the gout is oftentimes in an undeveloped form. 
To use a common term, it " hangs about the patient." Now, so 
long as there is uric acid freely circulating throughout the system, 
so long will it be difficult to make a satisfactory progress with the 
eczema. If there be marked gouty symptoms, with loaded urine, 
the ordinary treatment for gout may be used with benefit ; but in 
the so-called " suppressed ' ; forms of gout the value of saline 
aperients, guaiacum, and iodide of potassium is incontestable. I 
think highly of such w T aters as those of Friedrichshall and Mari en- 
bad in such cases in the morning, so as to empty the gastrointes- 
tinal canal freely. The addition of an equal volume of hot water 
increases their aperient action. Beer must be forbidden, together 
with sugar, pastry, and condiments. 

(6). INervous depression in connexion with mental distress or 
pure excitement is common as the general condition associated 
with eczema. The treatment is obvious — nervine tonics. Arsenic 
is often beneficial in these cases (see Formulae 151 to 157) ; but 
quinine, bark, and acids, with the milder sedatives, are better. I 
quite agree with Dr. Fraser, that in those cases in which there is 
marked hyperesthesia, or, to use more homety language, intolerable 
itching, strychnine (Formula 173) does much good. I am sup- 
posing that, under all the circumstances named, at the outset, 
when the inflammatory symptoms run high, salines and aperients 
are given first of all, in connexion with local remedies, to allay 
the inflammation. I also assume that anaemia is treated with its 
appropriate remedy. 

(7). It is very important to attend to deficient kidney-action, 
especially in eczema rubrum of the legs, in old or oldish persons, 
and in the eczema of children. Some of the best results I have 
ever obtained have been by the use of diuretics freely given under 
these conditions, and I have no little faith in the employment of 
digitalis as one of the ingredients of the diuretic compound in 
adults. An eczema rubrum will often rapidly improve when the 
quantity of urine passed rises to a goodly amount from a scant 
quantity before. The local treatment is, however, of much 
importance in these cases. 

(8). It has fallen to my lot to see a goodly number of cases of 
eczema — and general eczema too — show themselves as the first 
apparent evidence of a general break-up in old people ; and in 
these cases 1 have oftentimes found a dilated and hypertrophied 
heart — not always, it is true ; now and then dropsy has come on, 
or chronic bronchitis of an annoying kind. The general treatment 



192 TREATMENT OF ECZEMA RTJBRUM. 

consists, first of all, in remedies calculated to prevent or remove 
the effects of the heart mischief. 

It will be noticed* then, that there are many different disorders 
of health which can be very definitely fixed upon as influencing the 
course of an eczema, and these must have each its appropriate 
remedies, nsed in connexion with ordinary anti-pyrexials in the 
earlier stages of eczema rnbrum. 

Purgatives I do not think have any special curative effect in the 
case of eczema ; they merely aid the action cf other remedies by 
clearing out the primae viae, and so give the liver and kidneys a 
better chance of eliminating effete products. 

But supposing the acute stage to be passed, and the eczema to 
be getting chronic and scaly, arsenic is really of service in some 
cases, under such circumstances, if the disease is extensive and 
markedly scaly ; if. the patient is of a nervous temperament, and 
there are no decided secondary changes in the skin complicating 
the eczema. In those cases where the cellular tissue is involved, 
and there is a disposition to induration, I think alterative doses 
of bichloride of mercury and bark of infinite service ; and here I 
agree with Dr. Fraser in regard to this treatment. I have now 
and then seen cases of eczema rnbrum in a chronic state, in which 
there has been a remarkable puffiness, evidently oedematous, almost 
amounting, in fact, to a dropsical state of the skin, and this in 
young subjects. Here diuretics have benefited considerably, in 
alternation with cod-liver oil, iron, quinine, iodide of iron, and 
the like. 

Local Treatment. — In regard to the local treatment of eczema 
rnbrum, the lesson all need to learn is the avoidance of 
irritants. Suppose that the disease affects a large part of 
the body very severely, and that there are great heat and 
burning of the skin, what is to be done? Perfect rest must 
be enjoined, and the parts, if not freely discharging, are to 
be kept excluded from the air in some manner or other. It 
is not always an easy matter to say what will soothe in any 
particular case. Bran infusion, or decoction of marsh-mallow or 
poppy-heads, to which a little clarified size has been added, are 
very good applications to start with as lotions night and morning. 
The linimentum aquae calcis is sometimes efficacious. After 
bathing the parts in either of these liquids (and care should be 
taken not to sodden the skin), two courses may be adopted — the 
one is to apply absorbent powders to exclude the air, the other to 
use the mildest neutral unguents. If there be any discharge, the 
former are the best, and equal parts of starch and oxide of zinc 
form an excellent powder for the purpose. Dr. Anderson gives a 
very good prescription of the kind, containing camphor in the 
proportion of half a drachm or so to an ounce. In the case of 
the poor, nothing is perhaps so convenient as ordinary whiting, 
made into a thinnish paste and applied with a brush. But, if 



ECZEMA RUBKTJM. 193 

powders (see Formulae 77, 78) are used, they should be removed 
very carefully every twelve hours, and then poppy decoction or thin 
gruel may be applied for the purpose. When the surface is ceasing 
to discharge freely, or is not weeping so much, but is hot, stiff, 
glazy, and irritable, unguents are preferable ; but these will 
disagree if at all rancid. The best I know is the compound lead 
ointment of the old London Pharmacopoeia, or litharge ointment, 
(see Formula 121) which should be perfectly fresh, and never used if 
it be more then nine or ten days old. The application must be 
carefully made. The ointment should be spread on strips of old 
linen, and these are to be adapted closely to the affected surface. 
The patient, if the disease be general, should be packed in oint- 
ment, absolutely to exclude the air. The ointment must be renewed 
every ten or twelve hours. The benzoated oxide of zinc ointment 
is also good, but I have a preference for the other. Now, if the 
simple treatment above described agree, it should be steadily 
pursued for some time, until the heat, redness, and swelling subside. 
It may be well to prescribe, in addition to the above remedies, if 
the irritation is not relieved, an alkaline and gelatine bath each 
night. I have seen a great deal of harm done by the application 
of ointments containing mercurial compounds, in the inflammatory 
stage of eczema, and they should be avoided. When the sub-acute 
condition is reached, the time has come for the use of lotions, in 
addition to alkaline and gelatine baths. I prefer calamine and 
oxide of zinc lotion, about half an ounce or an ounce of each, with 
two drachms of glycerine and from six to eight ounces of rose or 
lime-water. The parts are bathed with thin gruel, and cleansed 
twice a day, and the lotion is applied with a piece of sponge or 
camel's-hair pencil very freely several times in the twenty-four 
hours. The compound lead ointment may be used at night if the 
lotion seem to be " too drying." In old people, where the skin is 
dry, red, and itchy, wet packing on a small scale at night, with dress- 
ings of Hebra's litharge ointment (see Formula 121), or the benzoated 
oxide of zinc, to which, a small quantity of carbolic acid has been 
added, are serviceable. In these cases the water-dressing oftentimes 
gives great relief. But there is still one more point relative to 
acute eczema : it is the necessity for the removal of the crusts 
which form, and the prevention of their re-collection. Patients 
are most obstinate in dealing with this matter. It is most diffi- 
cult to get them to understand that the remedies are required to be 
brought into contact with the surface beneath the crusts. The 
crusts should be removed by rubbing in oil or glycerine, or by 
poulticing. Once off, it is best, by the use of unguents, to prevent 
their re-formation. Even in the case of the scalp, the skin can be 
kept clean and free from crusts if a little trouble is taken in 
smearing the ointment fairly over it. It is proper to cleanse with 
warm water and white of egg once a day at least. I seldom use 
any other remedies than those already enumerated for the acute 
13 



(^ 



194 ECZEMA RUBRUM. 

stages. In the transition between the acute and the chronic forms 
of disease, where there is a little weeping, lotions of calamine and 
oxide of zinc are stiil the things to which I trust. When, however, 
the discharge is ceasing, if the surface be indolent and semi-livid 
from congestion of the skin, especially if a whole leg or arm, 
for example, is affected, the best possible results are to be obtained 
by the careful application of diachylon spread on thinnish linen. 
"Where the circulation remains languid, I sometimes use a solution 
of caustic in nitric ether. So much for acute eczema and its 
treatment by soothing remedies. 

Now the moment the discharge feature lessens, the swelling 
goes, and squamation approaches, the disease is to be regarded as 
chronic ; and I begin a very different and an active kind of reme- 
diation. As regards general remedies, antiphlogistics, active 
aperients, antimonials, and alkalies give place, unless there be any 
special indications for their continuance, to tonics, so-called speci- 
fics, and medicines for diathetic conditions. These I have referred 
to, but I must speak especially of the local treatment. For con- 
venience sake, I divide the instances of chronic eczema which are 
to be treated into three groups : — The first class comprises those 
stages of eczema in which the disease is slight, the textural altera- 
tion is more or less superficial, and the scaliness is distinct, 
but in which there is no crusting. The second, in which the 
scaliness is also well marked, but in which there is a good deal of 
infiltration into the skin, with occasional weeping, and a tendency 
now and then to the formation of crusts. The third, in which 
there is considerable thickening of, and infiltration of serous or 
plastic matter into, the diseased surface, in which itching is 
marked, and the eczema assumes a papular aspect. Astringents 
and absorbents (see Formulas 39, 40, 67, 75), do for the first class 
of cases — nothing else is needed ; tarry compounds (Formulas 83, 
84, 107, et 8eq.\ for the second, which approach psoriasis in aspect ; 
and the so-called soap treatment (Formula 82), is best adapted for 
cases in the third group. The use of astringents — such as weak 
lotions of sulphate of zinc, alum, borax, and applications like 
glyceral tannin — often suffice to complete the cure of chronic 
eczema where the affection is mild ; but experience shows that 
mercurial preparations are equally efficacious, and custom has 
given them preference in such cases. I use generally the nitric 
oxide of mercury ointment, or one composed of five grains of the 
white precipitate to the ounce, or citrine ointment diluted with 
jive or six parts of adeps, with or without oxide of zinc, to slight 
scaly eczema of the scalp, the face, the legs, ears, and other parts. 
Occasionally a weak solution of nitrate of silver has seemed to me 
to do wonders. I cannot say that I like sulphur, having seen so 
many cases aggravated by its most injudicious use. Where the 
eczema approaches in aspect to psoriasis, recourse my be had to 
the aid of tarry preparations, with excellent results, because all 



ECZEMA RUBRUM. 195 

that is needed is to rouse the skin by stimulation to healthy action, 
and tarry preparations are admirable stimulants. It is no bar to 
the use of tarry compounds that itching is present, but rather the 
reverse. I do not say that tarry preparations are not of service in 
other forms of eczema, but par excellence are they beneficial in 
their action in the quasi-psoriatic eczemata. But it is not always 
a matter of certainty to say whether tarry compounds will agree 
well with an eczema. To a certain extent one must be guided by 
experiment. This I may say, that in those instances in which 
there is much dry scaliness, accompanied by obstinate itching and 
the formation of true papules, they should be tried. I confess 
that I have a preference for the pyroligneous oil of juniper over 
all other similar preparations, and use it in the proportion of one 
to four drachms to the ounce of adeps. The liquor carbonis 
detergens and oleum fagi, however, are good. I do not find my- 
self so firm a believer as some in the virtues of carbolic acid as a 
panacea for all skin affections. Tarry preparations must be ap- 
plied to the real diseased surface; that is to say, we must by 
water-dressing or greasing, get away all scales and scabs from 
eczematous patches before using the remedy. Xow, it is acknow- 
ledged on all hands, as indicated before, that tarry compounds 
disagree with many cases in which d priori they would be thought 
to agree, and I have seen eczema often aggravated, and even tar acne 
induced. I have said they are most efficacious in the papular 
aspect of eczema, but I stated in speaking of the characters of eczema 
that dermatologists had not made proper distinction between the 
true papules o± eczema, and erected and congested follicles ; and 
this brings me to notice one point upon which I lay great stress in 
the treatment of eczema. Whenever there is a papulation around 
an eczema which has been much inflamed, it will generally be 
found that the follicles are irritated and congested. A careful 
examination will very soon tell if this supposition be true. If so, 
I conclude that there is considerable perversion of the innerva- 
tion of the integuments ; that the skin is very irritable, in fact ; 
that any stimulant treatment is sure to do harm ; and that, not- 
withstanding the eczema-patch itself is dry and scaly, the treat- 
ment must differ essentially from that adopted in similar cases, 
because of the indication afforded by the follicular congestion. In 
these cases the strapping with diachylon acts admirably. I believe 
that it is from the circumstance that tarry compounds have been 
used without distinction as to the diverse nature of the cases which 
make up papular eczema, that uncertainty exists as to their action. 
If we recognise the difference between true papular eczema and 
the condition induced by follicular congestion, we shall be much 
more cautious in our use of tar for the future. We must be 
specially careful in our use of tar in cases of eczema rubrum, and 
should abandon it if it increase rather than allay the itching, if it 
augment or induce any discharge, or lead to swelling or redness of 
the skin. 



196 ECZEMA EUBETJM. 

In the case of eczema affecting the fingers and toes, where there 
is no little pain and heat, with Assuring, it is a good plan to soften 
up the parts with some simple ointment — the benzoated oxide of 
zinc — and then to dress the parts carefully with diachylon plaster 
cut up into strips and adapted to the surface. If the cracks are 
very severe, the application of nitric acid will be decidedly bene- 
ficial. Where there is much thickening, the soap treatment, to be 
described directly, should be had recourse to. 

Thus far I have spoken of the simplest chronic eczemas in their 
scaly stage, and of those instances of chronic eczema arising out 
of eczema rubrum especially, in which there is slight infiltration, 
and therefore some thickening, and also squamation ; but there 
is yet the treatment of the third form of chronic eczema to notice. 
The cases to which I now refer are all those in which, as I have 
said before, the results of chronic inflammation replace, as it were, 
the eczema. As a consequence of the antecedent inflammation we 
have infiltration of plastic or serous material into the tissues of the 
affected part, with induration, hypertrophy of the cellular tissue, 
warty papillary growths, and the like, culminating in false elephan- 
tiasis (Arabum), or more properly bucnemia. In the less severe 
cases, blistering and the soap treatment are the two chief means 
of cure ; and I particularly wish to urge practitioners to use the 
latter more frequently in such cases as those, to which I now 
refer. Some dermatologists use potassa fusa, iodide of mercury, 
or iodine, to cases of chronic eczema with much thickening. But 
I do not recommend these ; and we must remember that we may 
lose our patient very readily if we use too violent measures. I do 
not, for this reason, very much like blistering. Mr. Gay tells 
me, however, that in his hands it has proved most beneficial ; and 
he is not singular, I am aware, in this experience. 

As I have said before, the soap treatment is the one I prefer in 
the general run of cases. Ilebra has done essential service to 
therapeutics in bringing this mode of cure so prominently before 
the notice of the profession. The way to use the soap is as follows : 
take a small portion of soft soap, and rub it freely into the 
thickened patch by the aid of a piece of flannel, wetting the latter 
from time to time, as Ilebra says, to make a lather. When dis- 
tinct soreness is felt, the inunction should be stopped, and the part 
wiped fairly dry. The part is then to be very carefully covered 
with some mild ointment spread on linen, and in such a way that 
air is entirely excluded. The best is the litharge ointment of 
Ilebra. The application of soap and unguent should be made 
twice a day. After a day or so the patch, softens up, but exhibits 
small red points, which may vesiculate ; the treatment is to be 
continued until these latter disappear. The practitioner will notice 
by the cessation of itching, and the general smoothing of the 
patch, when improvement is in progress. Of course this plan of 
treatment can only be used to really chronic eczema. We are 



ECZEMA BIPETIGINODES. 197 

accustomed to see thickening of eczematous patches mostly about 
the leg. The soap treatment, with bandaging, and the exhibition 
of iodide of potassium, or mercurials, internally, with diuretics if 
needed, do certainly work very remarkable cures, as the rule. Rest 
may be required, and firm strapping, in the cases of false elephan- 
tiasis. 

ECZEMA IMPETIGINODES. 

Nothing has been said as yet relative to the management of 
eczema impetiginodes. Of course, in those cases where the pus- 
formation is accounted for by the intensity of the inflammatory 
action, antiphlogistics, salines, and aperients are required at the 
outset, with the ordinary local treatment suited to eczema ru- 
brum. But this is not the case where the pus-formation is out of 
all proportion to the local inflammatory action, where it is clearly 
due to the existence of a well-marked pyogenic habit of body ; and 
this applies as well to the case of the infant as the old man. Here, 
a building-up instead of a pulling-down plan of treatment is called 
for. In true eczema impetiginodes, the diminution in the pus- 
formation is to be brought about by the use of general reme- 
dies — cod-liver oil, steel, quinine, good food, fresh air, and the 
like. I press upon the attention of the reader this point respect- 
ing the relation between the pus-formation, and the degree of 
inflammation on the one hand, and the existence of the strumous 
diathesis on the other. The local treatment of impetiginous eczema 
is, in the early stages, that of eczema rubrum entirely. At the 
outset, and in direct proportion to the degree of irritation present, 
our remedies must be of an emollient nature. Poulticing or foment- 
ing with decoction of poppy-heads, to remove the crusts and allay 
inflammation, is the first step. Weak lead or borax lotion may 
then be used, and subsequently an ointment made of a drachm of 
the nitrate of mercury, or three grains of the ammonio-chloride to 
an ounce of lard. If the scalp is affected, the hair must be cut 
from around the disease. Pediculi are to be destroyed by the 
white precipitate ointment, chloroform vapour, or a pyrethrum 
roseum, or stavesacre ointment. I prefer the former of these. In 
many cases alkaline lotions are of use — ex. gr., carbonate of soda 
(sixty grains to six ounces of water). In the later stages I never 
get beyond the use of the simplest astringents or weak white 
precipitate ointment, because all active stimulants and irritants re- 
produce or increase the pus-formation. In impetigo scabida other 
steps must be taken ; the general health must be regarded from, a 
gouty, a rheumatic, or a latent strumous point of view, and treated 
accordingly — the kidneys especially made to act well. The diet 
should be good and unstimulating. Then locally, the scabs are to 
be removed by repeated soaking in glycerine lotion, and by poul- 
ticing, and the denuded surfaces may be treated with lead lotion, 
tannin, and glycerine at first, and then the white precipitate oint- 



198 ECZEMA LMPETIOINODES. 

ment, or one composed of pyroligneous oil of juniper two drachms, 
and sulphur ten or twelve grains, to an ounce and a half of lard. 
Finally, painting with nitrate of silver solution will heal the sur- 
face : and if the limb is affected, and the skin is much swollen, 
careful bandaging must be resorted to. In impetigo of the beard 
hot fomentation, the exclusion of air as much as possible, a course 
of iron with acids and sulphate of magnesia, and locally alkaline 
washes, then glyceral tannin, sulphate of zinc lotion, and the 
nitric oxide of mercury ointment, generally suffice. In eczema 
infantile, what is needed besides is attention to the diet, which 
should be good, and regularly given ; such things as corn-flour made 
up with water are to be condemned, and good milk, with Robb's 
biscuits, substituted, at the rate of two pints of the former per 
diem for the young, if the mother is weak and cannot nurse 01* is 
unfit for nursing. If any teeth are through, good broth may be 
given once a day. Then the secretions, if pale and unhealthy, 
should be rectified ; and if the child is pale, steel wine given. I 
do not much care for arsenic, but it is fashionable, and it does good 
in scaly eczema. As I said before, a weak ammonio-chloride of 
mercury ointment is the best local application in the more chronic 
stages. 

I have thus laid down the principles upon which we should, as I 
think, conduct the treatment of eczema. 

As regards mineral waters, I will simply say that dyspeptics may 
take Marienbad and Karlsbad, or V als. Aneemics : Pyrmont, Fran- 
zensbad, or Tunb ridge Wells. Gouty subjects : Yals or Lithia 
water. 

For special internal remedies, see selected Formulae, Kos. 151, 
152, 153, 154, 180, 182, &c. 



CHAPTER XL 

BULLOUS DISEASES AND ANOMALOUS FOEMS OF BULLOUS EBUPTION. 

Under this head I include the diseases which are especially cha- 
racterized by the occurrence of bullaB as primary and essential 
phenomena. "Willan described a bulla or bleb as " a large portion 
of the cuticle detached from the skin by the interposition of a trans- 
parent watery fluid." In fs»ct a bulla is a large vesicle (see p. 32). In 
the wide sense of the term several diseases are really bullous, such 
as erysipelas, herpes, pemphigus, rupia, eczema of the fingers, and 
impetigo contagiosa. But of these there are only two that really 
rank under the term bullous — i.e., herpes and pemphigus. Ery- 
sipelas belongs to the class of zymotic diseases ; rupia is always 
syphilitic, and of course it is grouped under that head ; the bulla 
produced by the coalescence of vesicles in eczema is an accidental 
and secondary phenomenon ; and in impetigo contagiosa, the pri- 
mary stage is a vesicle and not a bulla, the secretion subsequently 
becoming sero-purulent, whilst the general behaviour and outward 
aspect of the disease are those of an impetigo. Besides, herpes 
and pemphigus are peculiar and alike in regard to the influence of 
the nervous system in their production. Therefore, true bullous 
diseases, or those which are probably of neurotic origin, and in 
which the bullae are primary, with transparent contents, are herpes 
and pemphigus. 

I might have placed these two diseases — herpes and pemphigus — 
under the head of neurotic diseases, but then I must have in- 
cluded many others, such as urticaria, pityriasis rubra, &c, with 
them, if I carried out the idea of collecting together under one 
head all those diseases which primarily originate in disturbance 
of the nervous system, and arranged them upon a pathological 
basis. As I have classified diseases, however, " clinically," I place 
herpes and pemphigus under the convenient but most unscientific 
term, "bullous inflammation," because it is to changes implied 
by that term that the practitioner first directs his attention in the 
matter of diagnosis and treatment. 

Some anomalous forms of eruption will be noticed at the latter 
part of this chapter. 

The French, as is well known, are exceedingly fond of assuming 
the existence of a special diathesis in connection with which her- 
petic eruptions are said to occur. The term herpetism has been 



200 HJflJiFES. 

coined to designate this general condition, the existence of which 
I of course wholly deny. Those, however, who wish to make 
themselves acquainted with French notions should consult a work 
of some 468 pages by M. le Dr. L. Gigot-Suard.* This gentleman 
seems to make herpetism include everything — erythema, prurigo, 
urticaria, psoriasis, lichen, acne, furuncle, herpes, eczema, ecthyma, 
hyperesthesia, &c, &c. His definition is as follows : " Maladie 
constitutionnelle, chronique, hereclitaire, on acquise, non-conta- 
gieuse, continue ou. intermittente, caracterisee par des manifesta- 
tions variees qui se produisent simultanement ou alterativement 
sur lapeau et divers systemes organiques, lesquelles manifestations 
ont pour cause directe la presence en excesdeprincipesexcrementi- 
tiels dans le sang, notamment de ceux qui s'y trouvent en tres petite 
quantite a l'etat normal, et qui ne sont pas excretes par la peau, 
tels que les urates, les oxalates, les hippurates, la xanthine, la 
creatine, &c." It will be at once evident that conditions of blood 
impurification that may act as exciting causes or aggravants of skin 
eruptions are magnified into verm causm in the attempted establish- 
ment of a special herpetic diathesis. 

HERPES. 

This disease is characterized by the presence of vesicles larger 
than those of eczema, distinct from each other, and invariably 
seated upon an inflamed base ; these large vesicles, which are 
chambered, may be regarded as small bullae. They are generally 
tolerably few in each separate collection of vesicles : they do not 
rupture, as the rule : but their contents, which are alkaline or 
neutral when clear, and slightly acid when turbid, after becoming 
opaque, disappear by resorption, but now and then by rupture and 
desiccation into light brownish scabs. The vesicles last about seven 
or eight days. The disease is mostly accompanied by sensations of 
heat, tension, and burning, which indeed are felt to a greater or less 
extent before the appearance of the eruption ; occasionally severe 
neuralgic pains occur before, together with, or after the eruptive 
stage. This is particularly the case in what is called herpes zoster 
or shingles. 

It is usual to make several varieties of herpes, but I think it 
only necessary to particularize the variety called herpes zoster, 
or shingles. It is of some importance, however, to distinguish 
between herpes which is the sole disease present and herpes occur- 
ring as part of — in the course of — general pyrexial diseases, as in 
the case of fevers and the exanthemata, rheumatism, &c. In the 
latter case the mucous membrane of the throat, mouth, or palate 
may be attacked as well as the skin. 

Herpes, when it exists as the sole disease, may be general or local. 
There seems to be little doubt that very occasional] y herpes may 

* L'Herpetism ; Pathoganie, Manifestations, Traitement, &c. Paris, BaiUiere et 
Fils. 1870. 



HERPES. 201 

be pretty general, and apparently without being a mere complica- 
tion of diseases. Dr. H. Coutagne, of Lyons,* particularly, has 
recorded a certain number of cases of " acute general herpes," which 
he thinks show that herpes may run the course of an exanthematous 
fever. The disease begins as a pyrexial disorder, with fever, head- 
ache, malaise, and the like, followed by the outbreak of a copious 
eruption about the face, limbs, and trunk, and what is curious, par- 
ticularly about the penis and the scrotum, and also in the throat, 
which is rendered painful. The disease lasts ten days or more and 
may relapse, but is unattended by sequelae. It may be confounded 
with acute eczema, pemphigus, the erythemata, miliaria, syphilis, 
and hydroa. Of course this form of general herpes is very rare, and 
may be after all only a consequence — i.e., symptomatic of some spe- 
cific febrile disturbance, or it may be the result of severe catarrh only. 

The localized forms of herpes however are the only forms 
of any frequency. They only differ in seat, and in the mode of 
arrangement and number of the collections of vesicles. I will 
briefly describe them for the student's sake. 

Herpes in its ordinary local form is observed in many parts com- 
mencing by a sense of heat and itching, with some erythema, upon 
which arise round grouped vesicles, from ten to twenty, in patches 
the size of sixpence to a five-shilling piece, surrounded by a red 
areola ; there are generally several of these patches ; they mostly 
occur about the face, arms, neck, and upper limbs. The contents of 
\the vesicles, at first transparent, become milky, then quickly disap- 
pear ; the vesicles shrivel, and scabs remain ; the smarting heat and 
tension also subside; the disease lasts ten days or more; the 
vesicles arrive at their height of development in two or three days, 
aid dry up on the seventh or eighth. 

Herpes labialis, named from the disease attacking the lips, 
conmences as a " cold," with pyrexia, &c. ; then the local heat, 
sma-ting, and tension are followed by a patch of herpes, with 
abort six or eight vesicles. 

HprcBjpiitialis is not uncommon ; the patch scales over in a week 
or so\ the scabs fall off, leaving little ulcers the size of pins' heads 
or mote, which quickly heal, the prepuce being irritable and red. 
There is a syphilitic herpes. In it there are successive crops of 
vesicles but the prepuce gets hard and indurated about the seat 
of the herpes, coition being painful. The mucous surface is more 
or less irdtable, and the origin from bullulse clear ; but the bullae 
give plafee to little ulcerations, which are close together, and 
quickly s-ab over ; in other cases, the vesicles abort, desiccate, 
and scale tver ; the little crusts fall off, leaving little pits, which 
presently heal (see Syphilis). 

H. zoste^ zona, or shingles,\ possesses the characters of 

* De l'Herpe^Generalise Febrile. Paris, 1871. 

f See paper b\ Mr. Hutchinson : London Hosp. Reports, voL iii. 1866. See 
also Sydenham ^> c . Year Book for 1867. 



202 HERPES. 

ordinary herpes, but derives its special name from the peculiar 
manner in which the groups of vesicles tend to encircle one-half 
of the body like a girdle. It follows the course of one or more of 
the cutaneous nerves, generally stopping short at the median line 
before and behind, though it may cross this point, and in this 
matter the experiences of Hebra, Wilson, Startin, Hutchinson, and 
myself agree. It generally affects the trunk, but may attack the 
face, the shoulder, the belly, or upper part of the thigh ; the right 
side is more frequently attacked than the left. Of 178 cases col- 
lected by Barensprung, in 101 the zoster was on the right side. 
It may attack both sides at one and the same time, but this is very 
rare, and when this form of zoster occurs it is not unlikely to 
be syphilitic, but I have seen unilateral syphilitic herpes. The 
disease is most common in the young; it is of about equal 
frequency in the two sexes, and occurs particularly during change 
of weather. It seems on some rare occasions to be almost epidemic. 
Zoster is. an acute disease, of definite duration, lasting from four- 
teen to twenty days. The patient often ails a few days before the 
eruption appears, is feverish, out of sorts, complains of headache, 
shivering, perhaps pain in the side, which may be very acute and 
of neuralgic aspect ; presently patches of erythema appear, and 
present, on close examination, a number of little white points, 
which quickly enlarge into bullulae, perhaps coalescing and forming 
distinct bullae ; the vesicles are tense, and contain clear serosity ; 
in four or five days they become partially emptied and flaccid, the 
contents becoming turbid and dark; at the same time the red 
blush fades, and the patch scabs over; the crusts disappear in ten 
days or so, leaving dark red stains. The changes are not completed 
at the same time over the whole area of the patch, but are later in 
taking place in one part than another — consequently, several 
aspects or stages may be noticed in different parts of the sime 
subject. In some rare cases, the H. zoster may ulcerate, or 3ven 
become gangrenous. Pain may be a very prominent symptom ; it 
may be lancinating, smarting, or burning. The convalescence 
finds the patient weak and neuralgic. The scars are not hst for 
some time. The disease rarely occurs twice in a lifetime, but I 
have known it occur a third time. It is usual to make certain 
varieties of zona or shingles. Roughly stated, they are Z capitis, 
faciei, nuchse, brachialis, pectoralis, abdominalis, and funoralis. 
It is as well to know that the eruption follows the coure of dis- 
tribution of certain nerves: the trigeminal in IT. facialis. the labial 
branch in IT. labialis, &c. &c. When the limbs are atUcked, and 
this is the case now and then, the line of eruption coresponds to 
that of the long axis of the limb ; in other words, tie eruption 
does not encircle the limb. A want of knowledge in this respect 
I have known to mislead observers. 

Now on comparing the above forms of herpes, me finds that 
they are not different, save in seat and extent. Thf herpes of the 



HERPES. 203 

nose, month, and ear, are identical. At one time it was customary 
to divide herpes into two kinds : the one (typical) including the 
varieties above described being called H. phlyctenodes, the other, 
including two sub-varieties, herpes iris and herpes cireinatus, being- 
ranked under a group designated eircinate. But this division is 
wholly unnecessary. Occasionally the patches of herpes may be 
peculiarly circular, and then the term herpes circinatus may be 
applied to it, though this refinement of nemenclature I discard. 

Herpes circinatus however was formerly the term applied to 
ringworm of the surface {tinea circinata) because of the presence of 
quasi vesicles or papules which formed in many cases at the circum- 
ference of the patch. But the disease commences as a red scurfy 
spot, enlarging gradually in circumference, the central part be- 
coming paler and scaly : and it is likewise indefinitely prolonged 
unless properly treated. I have seen tinea circinata develop 
rapidly as a largish patch, with well-developed vesicles, and then 
look very much like herpes phlyctenodes ; but in all these cases 
the origin from a small red, itchy, scurfy spot, the papulation or 
vesiculation of the extending ed^e only after a while, the clearing: 
of the centre, and the slight desquamation should at once decide the 
nature of the disease. The microscope should be used if there is 
a suspicion of parasite, and in any circular eruption which has a 
furfuraceous desquamating centre. The disease, as before stated 
too, lacks altogether the definiteness as to outset and duration of 
true herpes. The cause of tinea circinata is the growth and irri- 
tation of a fungus, and it is easy to see that the aspect of the 
disease will vary with the luxuriance of the parasite and the con- 
dition of health of the attacked. I hope the name tinea circinata 
will be given to this ringworm of the surface, and it will not in 
future be confounded with herpes, with which it has only a simi- 
larity in external appearance. 

Herpes iris. — This variety commences as a solitary vesicle on an 
inflamed base, and subsequently in some cases new vesicles spring 
up around the primary one, in the form of a ring. The vesicles 
may run together into large bullae. In its more perfect form 
then it consists of a herpetic circular patch made up of concentric 
rings, there being generally a distinct vesicle in the centre. The 
different rings are of various hues, hence the term iris. It mostly 
occurs on the back of the hand in elderly people. It lasts six or 
seven weeks, and is apt to reapj^ear in the same person. 

Herpes impetiginij-ormis. — Under this term Hebra has described 
a rare form of disease. The following notes of a recent case under 
Hebra's care were given in the Lancet of March 23rd, 1872 : — 

"At the beginning' of June, 1871, a woman twenty-five years old, and in the 
ninth month of pregnancy, was admitted into Professor Hebra's small-pox ward, 
under the supposition that she was suffering from varioloid. She had teen ailing 
for three weeks, but her illness had only taken an acute course a few days 
previously. It began with lassitude and loss of appetite ; she soon became so weak 



204 HERPES. 

as to be unable to leave her bed, and had fever and repeated rigors. It was soon 
found that her disease was not small-pox, and she was transferred to a ward for 
general skin affections. At this time the character of the eruption was clearly- 
marked. At the root of the neck, on the front of the chest over the sternum, and 
around and between the mammae, groups of small vesicles had formed on an in- 
flamed base. The vesicles had enlarged ; their contents became cloudy and 
yellowish ; a number of vesicles had coalesced, and, bursting, had formed brownish 
yellow and adherent crusts. The skin around the vesicles was intensely inflamed. 
The eruption had first appeared on the external genitals. The labia majora, mons 
veneris, and the neighbouring skin of the abdomen and inner part of the thighs 
were, on the date of the patient's transference to another ward, covered with large 
yellowish crusts, and vesicles in various stages of development. 

"In the course of the following week groups of similar vesicles appeared on the 
face, over the whole chest and abdomen, on the arms (where the patient complained 
especially of severe pain), and on the front of the thighs and legs. Thus rather 
more than a fortnight after admission the eruption had reached its height, and the 
front of the body was almost entirely covered with yellowish crusts ; these began 
to dry up and exfoliate, first at the root of the neck, without the occurrence of 
ulceration and loss of substance. 

"At this time were found near the ankles several large bulke, containing slightly 
cloudy fluid, resembling those of pemphigus. The patient, who had some days 
previously complained of k cold along the back,' and had a pulse of 96, began to 
feel warmer ; her pulse was found to be 92. She had repeated rigors, and was so 
weak that she could not raise herself in bed. No observations were made of her 
temperature. Her treatment throughout was mainly expectant ; she was allowed 
chicken and wine, and anything she fancied. For the pysemic symptoms she took 
quinine, and a lotion composed of six grains of perchloride of mercury and one pint 
of lime-water was applied to the genitals. As the pain prevented her sleeping she 
was ordered half-drachm doses of chloral hydrate at night. On June 15th, Pro- 
fessor Hebra had, as an experiment, her left leg bandaged with strips of diachylon 
plaster, but without any striking result. 

" On June 17th the patient was safely delivered of a healthy child. This was 
her second pregnancy ; in the first she miscarried. On the 19th she was going 
on well, was cheerful, and the lochia was normal. The eruption was scaling round 
the neck. On July 5th she had a slight attack of hospital dysentery, and was 
treated with tincture Of perchloride of iron in fifteen-minim doses three times a 
day, and with dilute sulphuric acid. At this time she had no sign of any fresh 
eruption and was scaling rapidly. On July 25th, when the last note was taken, 
she was almost convalescent; her face (which was the part least affected) was quite 
normal, as also her chest, and the remainder of her body was rapidly becoming free 
from scales. 

" In some remarks upon this case, Professor Hebra said, that, in his very con- 
siderable experience, he had only as yet seen five such cases, of which this was the 
fifth. They all occurred in women at full time except one, which took place during 
the course of pregnancy ; the first four all terminated fatally. They all resembled 
one another in beginning in the region of the genitals ; in their general diffusion 
over the body in the later stage ; and in the herpetic character (groups of vesicles on 
the same inflamed base) which they presented. They were all accompanied by 
fever and rigors. The disease might be called ' herpes impetiginif ormis' from the 
appearance of the crusts. There was no restriction to the course of certain nerves 
as in an ordinary zoster. Finally, it was a most dangerous disease." 

Morbid Anatomy and Pathology. — The changes which take place 
in the skin in the formation of the groups of vesicles in herpes 
zoster have been defined with much exactness by Biesiadecki and 
Haight. The observations of these gentlemen have been noticed 
more or less completely in speaking of vesicles under the head 
of elementary lesions. "The normal papillse are enlarged by serous 
infiltration and by the presence of exudation corpuscles. The 
fusiform cells and connective-tissue corpuscles are increased in 
size and amount, and are found not only in the papillary layer, 



HERPES. 



205 



but also in the rete mncosum. In the papillary layer the fusi- 
form cells elongate so as to form a network, in the interstices of 
which cells lie. The result of this increase of cell-growth and 
serous exudation into the rete is to put the cells of the rete on 
the stretch, or to push them aside, so that loculi are formed, 
having for their roof nattened-out cells of the cuticle, and for boun- 
daries and partitions, the cells of the rete elongated into fibres. 

Fig. 17. 




Bulla of Herpes Zoster (after Haiglit. Sitzungsb. der k. Akad. , 1868). 
a. Thick strand formed of elongated spindle-shaped epithelial cells, b. 
Meshwork consisting- of spindle-shaped cells, b', b" cells with several 
prolongations. (Diani. 450.) 

And according to Biesiadecki the latter are formed also by the 
fusiform cells. The thicker bands of the meshes run from the horny 
layer of the cuticle to the interpapillary part of the corium, which 
is covered by a thin layer of pressed rete cells. The main network 
of the vesicle is portrayed as above by Dr. Haight. When pus 
forms the pus-corpuscles lie in the meshes of the network already 



206 



HERPES. 



described. The source of the pus-cells is supposed by some to be 
the epithelium, by others the coimective-tissue corpuscles, by others 
the white blood-cells. The vessels in the papillae are enlarged 
and dilated. But the most interesting facts remain to be noticed — 
viz., that there is distinct morbid change to be noticed in the 
nerve trunks underlying and in connexion with the seat of erup- 
tion, and also changes about the roots of the spinal nerves. 

As regards changes in the nerves at the seat of eruption it 
seems clear that the nerve is swollen, and the neurilemma filled 
with small round nucleated cells of the character of pus-cells; 

Fig. 18. 




From the deeper layer of the corium in herpes zoster ; densely com- 
pressed cellular tissue, a. Transverse section of a nerve with en- 
larged fibres, axis cylinder displaced ; loose cellular tissue around nerve 
interspersed with pus- cells. 



the medullary substance is also softened and the axis cylinder 
" eccentrically enlarged." The accompanying figure illustrating 
this state of things is Dr. Haight's* (fig. 18). 

But further than this it would seem that morbid changes are 
to be detected about the origin of the spinal nerves. Clinically 
two facts are certainly presented to the physician's attention, 
especially in zoster: — 1. The constant occurrence of neuralgic 
symptoms prior to the development of herpes, and of such a dis- 
tribution and character as to lead to the supposition that its cause 

* Loc. citato. 



HERPES. 207 

must be seated not in the skin but near the spine. Some of the 
most intense eases of " pleurodynia " are connected with zoster, 
whilst the pain is speedily relieved by the outbreak of eruption. 
2. The second fact is, the exact correspondence as to site of her- 
petic eruption with portions of the surface supplied by certain 
branches of nerves, whose main trunk far off from the seat of 
eruption must be disordered. Zoster of the chest will make its 
appearance frequently in the part supplied by the posterior 
cutaneous branches of the intercostal nerves, then in that fur- 
nished by the anterior and so on. A striking case is that recorded 
by Mr. Paget, in which herpes affected the parts supplied by the 
infra- orbital, the anterior dental, and the anterior palatine 
branches of the superior maxillary nerve. After catching cold, 
the patient was attacked on the third day with herpes of the 
cheek, side of nose, the upper lip, the palate, and buccal mem- 
brane. The final results were in some respects remarkable, and 
in keeping with the explanation as to the implication of the main 
nerve trunk. A bicuspid fell out on the sixth day, a second on 
the seventh, and later still the canine and two incisors, whilst 
the alveolus in part necrosed. In the herpes ophthalmicus, so 
fully referred to by Mr. Hutchinson, the same truth has been 
illustrated in a very remarkable way. But it is well known that 
Barensprung, who has investigated this matter very closely, gives as 
the essential cause of zoster, not disease of the actual nerve trunk, 
but inflammation of the sympathetic fibres of the spinal ganglia, 
which affects the tissues through the nutritive (tropic) nerves 
that arise from those ganglia ; others regard the eruption as due to 
simple vaso-motor nerve disorder; but as there is actual forma- 
tion of new products in herpes, Barensprung's views prevail. 
That the nerves determine the seat, and are the agents that 
excite the eruption is unquestionable. In a very suggestive paper 
by M. Prouet* he mentions that in one case of zoster under 
Barensprung's care, the spinal cord with the roots of the spinal 
nerves were found to be free from disease, but on opening the 
intervertebral foramina the sixth, seventh, and eighth intercostal 
nerves were found to be enlarged and reddened for the space of 
an inch, owing to the presence of large and tortuous vessels which 
traversed the neurilemma. The seventh, which was the nerve 
principally affected, was half as large again as the fifth or ninth. 
A similar case has been reported by M. Charcot, only that in this 
instance the spinal ganglia were red and swollen in addition to the 
other lesions. 

Recently AYyss has made similar observations in the body of a 
patient of Yon Witte's, of Rheinau, suffering from herpes. " The 

Eatient was sixty-eight years of age, and on September 16th he 
ad headache and febrile symptoms. On the 19th scattered 

* Archives de Medecine. 



208 HERPES. 

vesicles appeared of herpes labialis. On the 20th the right side 
of the forehead, and nose and cheek as far as to the border of the 
lower jaw, were injected. On the 22nd the right eye itself was 
inflamed, and on the 23rd, the left. Two days afterwards an 
eruption of herpes appeared on the right side of the face, which 
affected the cornea and conjunctiva. On the 28th the patient 
died. The post-mortem examination was conducted with great 
care. The herpetic vesicles and scabs were very accurately limited 
to the right side and to the parts supplied by the first branch of 
the right trigeminal nerve. The left eye was perfectly normal. 
The nerve above mentioned was found to be broader and thicker 
than that of the left side, of a deeper grey-red colour, of softer 
consistence, and with the several nerve fasciculi separated by 
greyish-red soft tissue, containing many vessels. This alteration 
in its character extended from the point where it entered the orbit 
to the finest branches as far as they could be traced with the simple 
lens. The other nerves traversing the orbit were perfectly healthy. 
Outside the orbit and extending from it to the ganglion Gasseri, 
the first branch of the fifth was surrounded by extravasated blood. 
On the proximal side of the ganglion Gasserianum the fifth nerve 
was normal in appearance. The ganglion itself was larger and 
somewhat more succulent than the left ; upon its inner side was a 
red mass that appeared to be caused by an ecchymosis. The proper 
substance of the ganglion was not of a yellowish-white colour, but 
bright red. The fifth nerve was healthy at its apparent origin 
from the brain, where it entered into the Gasserian ganglion. 
There were numerous ecchymoses. These were especially visible 
also in that part of the ganglion whence the first branch of the 
fifth arises, whilst that from which the second and third branches 
arise was little altered." {Centralhlatt, No. 7.) 

This case of course bears out Barensprung's theory that zoster 
is the result of inflammation of the spinal ganglia and the nerves 
passing through them. 

Gerhardt observes that the group of diseases in which zoster of 
the face occurs is remarkable "by the frequency of an initial 
rigor or the occurrence of an increase of temperature even to 
32 degrees Reaumur, on the first day." He thinks that the irrita- 
tion must be caused by the following peculiarity of the fifth nerve : 
"The branches run through narrow bony canals along with small 
arteries : these arteries contract in the initial rigor, but then dilate, 
and their abnormal size creates a pressure on the branches of the 
trigeminus and the sympathetic. The occasional result is the 
Occurrence of a vesicular eruption. "When this has once occurred 
an accommodation takes place in virtue of which a second attack 
of febrile dilatation of the vessels does not irritate the vaso-motor 
fibres so as to cause an eruption." It is curious that in inter- 
mittent fever herpes only occurs once, and as is held generally 
between the second and third fit. Be the value of Gerhardt's 



HEKPES. 209 

observation what it may, it possesses a certain amount of interest 
in connexion with the minute observations made by Barensprung, 
Wyss, and others. 

The pain of herpes zoster is supposed by Barensprung to be due 
to the reflection of irritation from the ganglia along the corre- 
sponding posterior nerves. In a very suggestive communication 
made to the Journal of Cutaneous Medicine, Dr. Woakes* remarks 
that "owing to the suspension of the regulating power exercised 
mainly by the sympathetic nerves over a given artery, effusion of 
fluid takes place from its ultimate ramifications ; these being distri- 
buted to the skin on the one hand, and to the texture of the 
sensory nerves on the other, the effusion so caused produces the 
herpetic rash in the former, and the pain from mechanical pressure 
in the latter ; " that is to say, the alteration in the calibre, &c, of 
the vasa nervorum, accounts for the pain. However, as I said 
before, the formation of new products seems to me necessarily to 
signify the distinct disorder of the trophic nerves in herpes, unless 
it be admitted that the new cell elements are produced from 
escaped white blood cells. 

The above considerations lead me to the enumeration of the 
exciting causes of the nerve irritation. In symptomatic herpes — 
ex., herpes occurring in fevers, ague, pneumonia, and in catarrh, 
it is not difficult to understand that disorder of the ganglia may 
occur. It is not difficult to understand the development of herpes 
after the passage of a catheter, or other irritation of the mucous 
membrane of the urethra ; but it is perhaps less easy to give an 
explanation of the occurrence of herpes after the action of an 
irritant upon the surface, as in exposure to cold, except by admitting 
Barensprung' s theory, and supposing that the sensitive nerves 
transmit impressions to the spinal ganglia, which subsequently 
influence the vasa-motor or trophic nerves going to the seat of the 
herpetic eruption. It is also easy to see that emotional distur- 
bance or mental distress may play an important part in the 
causation of herpes. But the typical mode of production is seen 
in labial herpes, where irritation of the mucous membrane of the 
air-passages is reflected upon the nerves going to the lip, giving 
rise to hyperemia and vesiculation. It should be mentioned that 
herpes zoster has been observed to occur during the exhibition of 
arsenic. 

Lastly, in regard to the pathology of herpes as a whole, I may 
state that the disease presents in many of its features a family 
likeness to the exanthemata, as observed by Willan. It has a 
definite duration ; it is anteceded by general pyrexial symptoms : 
and it presents eruptive phenomena, which are not successive, but go 
through stages of maturation and decline, as in the eruptive fevers. 

* " On the Correlation of Cutaneous Exanthemata with Neuralgia," by E. 
Woakes, M.D. Journal of Cutaneous Medicine, vol i. No. 3, Oct. 1809. 

14 



210 HERPES. 

The Diagnosis. — Herpes cannot well be confounded with any 
other disease. The red base, upon which a few large clustered 
though distinct multilocular vesicles (bullulge), larger than those 
of eczema, and smaller than pemphigus, are seated : with the acute 
regular course of the disease : its short duration : its non-secretory 
aspect, and the frequent presence of neuralgic phenomena, and 
ordinarily, of smarting, heat, and tension, are diagnostic. Erysi- 
pelas may resemble II. zoster ; but it is not unilateral, the bullae 
are large, the redness is accompanied by swelling, the edge of the 
blush is well defined, and rigors are present. 

Prognosis. — There is no anxiety whatever as regards herpes, save 
in the occurrence of zoster in persons of feeble constitution in 
advancing or advanced life. In this case great debility, and 
ulceration in the site of the herpetic patch, may result, and the 
special care of the physician will be needed to sustain the powers 
of the patient. 

The Treatment. — Usually the only thing necessary in the treat- 
ment of herpes is to protect the eruption from being irritated by 
the clothes of the patient and other external influences. This 
arises of course from the fact that herpes is a disease of definite 
duration, and that the eruption is, so to speak, its " explosion." 
The attendant nerve paresis, having produced the eruption, 
appears unable to secure the continuance of the disease ; and so 
one finds that when once the eruption is " out," relief from pain, 
from neuralgia, and the like, is obtained, and the healing process 
at once commences in the affected skin. It is only necessary 
therefore to help the reparative process set a going by nature. 

I use generally a lotion of oxide of zinc and acetate of lead with 
glycerine locally, and cover the patch over with a layer of amadou, 
or two or three layers of lint, in the early stage ; and subsequently, 
when desiccation has taken place, apply a cerate composed of elder- 
flower ointment an ounce, lead lotion a drachm, and prepared 
calamine powder two scruples ; but glycerine of tannin is equally 
good, and indeed may be used from the commencement. In zoster 
the eruption may be oiled over, and then dredged with flour freely, 
a layer of cotton wool being placed over all. The great thing is to 
avoid too much meddling. In some cases neuralgic pains are very 
severe : here poppy fomentations ; equal parts of the linimentum 
belladonnse P. B., and linimentum camphorse ; or olive oil and chlo- 
roform ; morphia dressing, or, if required, the hypodermic injection 
of aconite and morphia, are necessary. And under these circum- 
stances internal remedies are also to be used — especially quinine in 
full and repeated doses, ammonia and bark, or aconite or opium, 
as the case may be. After herpes zoster I always advise a course 
of tonics — the mineral acids and quinine with slight aperients. In 
certain other cases there may be special indications for general 
treatment, either by reason of pyrexia : or the debility of old age, 
for which bark and port wine and plenty of nourishing food are 



PEMPHIGUS. 211 

requisite. Should ulceration occur in zoster, nitric acid and opium 
lotion, or a weak solution of caustic (grs. x — xx) in nitric ether 
( | j) will be serviceable. In herpes iris nothing special is called 
for. In those cases which I have seen there was nervous debility 
present, and the mineral acids with bitters, and some astringent 
application locally, acted satisfactorily. Of conrse when herpetic 
eruptions occnr in the course of catarrh or fevers, the internal 
treatment is that which is fitting for the general disease. See 
Formulae, 39, 40, 47, 58, 60, 71, 72, 76, 77, 78, 88. 

PEMPHIGUS. 

This disease is characterized as regards eruption by the ap- 
pearance of little separate blebs, usually grouped in threes or fours, 
seated upon slightly inflamed bases, which are quickly covered over 
by the enlarging bullae. These blebs may attain a size varying 
between that of a pea and a hen's egg. They are distended with 
fluid, which is at first very transparent, but soon becomes milky. The 
fluid may be quickly reabsorbed, or the blebs or bullae simply shrivel, 
the distended globe becoming flaccid. Very often the blebs burst 
in a few days, and then the contained fluid dries into crusts of lamel- 
lar aspect, beneath which is very slight ulceration. The contents are 
sometimes sanguinolent. The bullae generally occur in successive 
crops ; they develop in the course of a few hours ; their outline is 
generally round or oval ; they may be confluent, but are usually 
distinct. Now and then a species of false membrane is contained 
in the bullae. The reaction of the fluid is generally alkaline, but 
with turbidity comes acidity. The local symptoms are, slight 
itching and smarting at the outset, and more or less soreness. 
The healing process in pemphigus is sometimes tardy, a thin ichor 
being secreted by the surface originally blebbed, and so a quasi- 
impetiginous crust is often produced. In rare cases in cachectic 
subjects, sloughing may occur. The disease attacks all parts of the 
body — but rarely the head, the palms of the hands, or the soles of 
the feet. Sometimes the mucous surfaces — ex., the intestines, 
vagina, &c., are the seat of bullae in pemphigus. 

Sow this general description applies to all varieties, about which 
much unnecessary fuss has been made. The term pompholyx was 
originally used to denote the chronic and most indolent form of 
pemphigus, but the two terms are now used in the same general 
sense. 

Pemphigus is almost always chronic, but there is an acute form ; 
and therefore, in accordance with most authors, I make two groups, 
acute and chronic. 

Acute pemphigus is seen in children, and is practically synony- 
mous with pemphigus neonatorum. Now the greatest doubt exists 
as to the nature of this affection. According to Dr. Steffen,* there 

♦Wiener Med. Wochenschr., Sept. 12, 1866. 



212 PEMPHIGUS. 

are three forms — (1) pemphigus occurring in children apparently 
healthy, and ending favourably ; (2) pemphigus in children who 
have been badly nourished, or who have fallen into a state of ma- 
rasmus, and in whom it is therefore the result of cachexia; and (3) 
syphilitic pemphigus. From all that I have observed and can 
gather, and basing my observations on such an epidemic as that 
which occurred in the General Lying-in Hospital in 1834-5, it 
seems clear to me that there is a non-syphilitic and a syphilitic 
form. When it is epidemic and occurs amongst the children in a 
lying-in institution, it seems to me to be the result of the opera- 
tion of acute blood-poisoning, such as that of puerperal fever; and 
perhaps the disease ought not to be regarded as a pemphigus. Ap- 
parently healthy children are seized with severe constitutional 
symptoms : the skin is livid, the areolae of the bullae are dark ; 
the contents foetid ; the ulceration is unhealthy, deep, its surface is 
dark, blackish, and exudes an ichorous matter, the edges being livid, 
shreddy, so that large circular, depressed, black, gangrenous ulcers, 
acutely produced, are present. The feet and hands may be affected, 
but also the limbs, the genital parts, the abdomen — even the 
mucous surfaces and head ; death occurring about the tenth or 
twelfth day. In other cases, in badly fed and overcrowded children, 
the disease may not be so severe, but presents much the same kind 
of changes. There is a purplish base to the bullae, sanguinolent 
contents, ichorous discharge, and a good deal of sloughing and 
gangrene ; the disease being propagated by successive crops for 
weeks, and the child often dying, worn out by irritative fever and 
exhaustion. This in fact is the pemphigus gangrenosus which 
Dr. Whitley Stokes described as occurring among the ill-fed Irish 
children. 

Pemphigus (neonatorum) acutus is also syphilitic, and occurs 
as a consequence of the cachexia of that disease. It occurs, not 
as an epidemic, but in connexion with other symptoms of con- 
genital syphilis, and is well marked about the hands and feet soon 
after birth ; it may give rise to deep ulceration. 

Chronic pemphigus. This occurs in the adult. At the com- 
mencement there may be headache and pyrexia ; in a couple of days 
or so, little red points appear ; upon these red points bullae form, 
which rapidly increase and fill : they may have areolae ; all de- 
pends upon the progress of the bullae. The latter and the red 
blush increase together, but generally not jpari passu, for the bulla 
overtakes the areola and hides it from view. In two or three days 
more the bullae burst, a raw surface is left, which scabs over, and 
at first the incrustation is yellow, then brownish. The bullae seen 
on the limbs and trunk are successive, and so prolong the disease 
for some weeks. When the disease occurs in a very chronic 
form, it is called P. diutinus, the ordinary form is called P. 
vulgaris. Sometimes there is but one bulla developed at one 
time ; this bulla is large and bursts in a day or two, crusting over, 



PEMPHIGUS. 213 

and disappearing, to be followed by another solitary bnlla. This 
variety of pemphigus occurs chiefly in old people who are debili- 
tated, and the hrst bulla appears after a little tingling about the 
ankle or the wrist. Five or six bullse in all show themselves. 
This form is styled pemphigus solitarius. These chronic forms may 
occur in children and young persons as well as adults. There are 
two more varieties. 

Pemphigus folicaceus is a very interesting variety. It com- 
mences on the front of the chest by a single bulla, and then by 
the development of others around, spreads over the whole surface, 
the bullse being more or less imperfectly formed ; the skin is red 
in many places, but there is not much infiltration ; nor is itching 
severe. After the bullse form, large yellowish squamse are pro- 
duced, with more or less desquamation ; the scales, which may be 
large, are the remains of imperfectly-formed bullse : they are free 
at their margins, and they are reproduced very rapidly. The 
bullse are successive and confluent ; oftentimes the skin exhales 
an offensive odour. The scales have been described as resembling 
French pastry, pieces of parchment, or papyrus, and vary in size 
from three-quarters of an inch to two inches. This is often a fatal 
form of disease, death being ushered in by irritation of the mucous 
surfaces and dropsy, especially in old people who are weak and 
out of health. 

Lastly, there is a form of disease in which the characters of 
prurigo and pemphigus are intermingled, to which the term 
pemphigus pruriginosus is given. The bullse are small and not 
well formed, though numerous, but the pruriginous itching is 
most distressing (see under the head of Anomalous Bullous Dis- 
eases, p. 220). 

Morbid Anatomy. — Microscopical examination has detected in 
the fluid of pemphigus what seem to be mucus and pus-corpuscles, 
but are thought to be newly-formed epidermal cells. Bamberger* 
declares that there is a great deficiency of solids, especially albu- 
men, together with an excess of ammonia in the blood, and an 
abnormal quantity of phosphoric acid in the urine. 

Haight has shown that the fluid in pemphigus is collected be- 
tween the layers of the horny portion of the epidermis. There 
do not appear to be any exudation corpuscles, and no increase of 
spindle-shaped cells to be seen in the skin, nor are loculi formed 
by their elongation. Pemphigus would seem to be the result of 
simple vaso-motor disturbance, and scarcely of disorder of the 
trophic nerves. (See p. 32.) 

The causes of pemphigus are involved in obscurity. 

Prognosis. — The cure is not rapid, but slow ; recurrence of the 
disease is frequent. In old people, where the disease is general, and 
in children, when there is ulceration, the issue of the case is often 

* Wurzb. Med. Zeitschr., 1860. 



214 PEMPHIGUS. 

unfavourable. The general condition of the patient must be the 
guide, and in these cases a cautious opinion should always be given. 

Diagnosis. — Pemphigus can scarcely be confounded with any- 
thing else, the bullae are so diagnostic a sign. In eczema of the 
hands, bullae may be produced secondarily by the confluence of 
vesicles, but their origin is readily traced, and co-existent eczema 
is to be found elsewhere. Pemphigus is rare on the hands and 
fingers, per se. General eczema and P. foliaceus should not be 
confounded ; in the latter abortive bullae are present, the scales are 
larger and peculiar, and the skin is not infiltrated. 

Li ecthyma cachecticum the pustules contain bloody fluid ; there 
are no true bullae in the disease ; the crusts are also thick and dirty ; 
whilst the ulceration is deep. In rupia, the bullae are smaller 
and flatter, the contents sanious, the crusts thick, dark, prominent 
— cockle-shell like ; the ulceration deep and foul. Pemphigus 
foliaceus resembles pityriasis rubra ; but in the latter there is no 
history of bullae ; the scales are altogether smaller, and they are 
imbricated in a peculiar manner. 

Sometimes in impetigo contagiosa, the bullae become somewhat 
large, but they are never distended as in pemphigus, but flat ; the 
contents soon become purulent, and flat yellow scabs form, which 
.are characteristic. The disease is clearly pustular. 

Treatment. — In the acute forms the disease must be treated as a 
typhoid disease : an aperient should be given at the outset, then 
salines, with ammonia, unstimulating nourishment — strong broth 
— and as soon as the pyrexia is at all subdued, tonics should at 
once be had recourse to, with quinine in full doses. In children, 
chlorate of potash and quinine, with wine, should be administered 
from the outset. In the syphilitic variety much the same line must 
be followed as regards the child, whilst the mother should be well 
toned up and well-fed. Slight mercurial inunction in children 
who are in sufficiently good condition to bear it, should be em- 
ployed. Then as regards local measures, weak solutions of per- 
manganate of potash and carbolic acid, with the use of absorbent 
powders, and presently, when the sores are cleaner, weak nitric 
acid lotion, seem to be the best. An ointment of scrophularia 
nodosa is advised by Dr. Stokes, in the gangrenous variety. In 
the chronic forms, good diet, with quinine — for I believe this to be 
the best remedy for pemphigus — the mineral acids, and arsenic, are 
the remedies usually employed internally. In many of the cases 
of pemphigus that I have seen, there has been a deficiency of 
proper meat in the diet, and a good deal of worry, the two together 
inducing an anaemiated and exhausted condition. In these in- 
stances, plenty of good food, with the mineral acids and cod-liver 
oil, and a due attention to elimination, has sufficed for the cure. 
Some cause of debility may usually be detected in patients, and 
that should be treated specially. I think, in many cases, that 
aperients combined with tonics are called for. If a half -starved 



BULLOUS ERUPTION. 215 

individual, or a debilitated subject, whose waste products have 
already overcharged the blood be fed or toned up without care 
being taken that proper emunctory work is carried on in him, the 
cure may be delayed. I have often seen this. In the more 
chrome forms, arsenic is regarded by many as the best remedy. 
I prefer quinine in full doses. In old people, pemphigus 
may be regarded as indicative of a " break-up." In such cases, a 
nourishing diet, quietude, and bark and acid are the best remedies. 
Locally, in these chronic forms of pemphigus, it is well to let out 
the fluid from the bullae, to apply some inert powder, such as lyco- 
podium, and subsequently weak astringent lotions, made of alum, 
tannin, ziuc : or even ointments of zinc ; and if the sores do not 
heal, to use a solution of nitrate of silver, gr. iij or gr. iv to 3 j of 
adeps, or to apply a weak white precipitate ointment. 

In the pruriginous variety, conium and aconite, or quinine, 
internally, with alkaline baths, and a lead or calamine and opiate 
lotion, may be employed. A very good application, to cool and 
comfort the surface in all cases, is a mixture of common whiting, 
glycerine, and water, made into a thinnish paste, and spread over 
the surface by means of a brush. 

ANOMALOUS FORMS OF BULLOUS ERUPTION : HYDROA. 

Under the head of neurotic diseases, and in connexion with 
herpes, attention may be directed to certain vesicular or bullous 
forms of eruption, which have been described by Bazin under the 
term of arthritic (gouty) hydroa.* Recently writers in England 
have described under the term hydroa this same affection, but, 
as it seems to me, mixed up with other forms of eruption ; since 
they have not properly distinguished between urticaria bullosa, 
erythema papulatum, sudamina, and the hydroa of Bazin. iSow I 
do not like the application of the term hydroa — which clearly 
signifies a disease connected with sweat — adopted by Bazin, the 
more so as I think his varieties of hydroa can be referred to herpes 
and pemphigus. I will, however, in the first place state Bazin's 
views, as far as I apprehend them, in reference to the particular 
disease which he describes as hydroa; and then give subsequently 
my own opinions upon the matter. 

Under the name, then, of arthritic hydroa, Bazin originally 
describes " an affection analogous to the ordinary herpes of Willan, 
characterized by vesicles or small bullae placed in groups, or at 
intervals more or less distant." Further, according to Bazin, this 
arthritic hydroa is herpes successive or remittent and chronic, 
and it is clearly connected with a gouty diathesis. Bazin dis- 
tinguishes three varieties of hydroa : — 1. Hydroa vesiculeux. 2. 
Hydroa vacciniforme, confounded with aphthae chronique (phlyctene 

* See Bazin's work, p. 192. 



216 BULLOUS ERUPTION. 

chronique of Alibert). 3. Hydroa oulleux (pemphigus, with small 
bullae). 

Hydroa vesicideux is generally confounded by authors with 
erythema papulatnm. First, as regards Seat : " It is developed on 
the cutaneous and mucous surfaces. On the skin it exists ordinarily 
on the uncovered parts — ex., back of the hands and wrists and on 
the front of the knees. In most cases the buccal mucous membrane 
is affected,- and then the eruption occupies by preference the lower 
lip and the inside of the cheeks, and appears after its development 
on the skin. However, in one of our cases, the base of the uvula 
was surrounded by a circle of vesicles. The conjunctiva may also be 
the seat of this eruption." 

Symptoms. — " It is sometimes preceded by malaise, anorexia, and 
a slight febrile attack, but these prodromic symptoms are often 
wanting, or are so little marked that the attention of the patient 
is first attracted by the development of the vesicles." 

Whatever be the seat of the eruption, it presents the following 
characters : — 

" There is seen at first spots of a deep red colour, small, rounded, 
a little raised, and with their edges clearly defined. These spots 
vary in size from that of a lentil to that of a piece of twenty 
centimes ; they are sometimes surrounded by a rose-coloured 
areola ; they show soon in their centre a small vesicle filled with 
transparent yellowish liquid. This vesicle appears the day following 
that of the red spot. It dries rapidly from the centre, which is 
occupied by a small blackish scab, whilst the liquid is absorbed 
from the circumference. The phenomena take place towards the 
second or third day of the eruption." 

The subsequent phenomena are as follows : — " The liquid in the 
circumference of the vesicle is reabsorbed, whilst that which oc- 
cupies the centre becomes a blackish scab. At last it may happen, 
especially during cold weather, that the fluid exuded in the vesicle 
is absorbed rapidly. It will then have only a small whitish or 
yellowish macula, placed in the centre of a red disc, and formed 
by loosened epidermis. In this case it is that the affection has 
been confounded with erythema papulatum. On the mucous 
surfaces the vesicles are whitish aud surrounded by a violet-coloured 
areola — the scabs are detached sooner. The red discs and vesicles 
are more or less numerous. They are generally separated by 
intervals of sound skin ; sometimes they are disposed in groups of 
two or three, touching at their circumference. They do not all 
appear at once, but by successive crops during many days. The 
affected parts have scarcely any itching. The febrile symptoms 
which exist rarely at the commencement cease when the eruption 
is developed." 

Duration and Termination. — " The duration of hydroa vesiculeux 
is from two to four weeks ; each element in the eruption taken by 
itself runs through its course in four or ~Q.we days. The affection 



BULLOUS ERUPTION. 217 

is prolonged for many weeks only by the eruption of fresh crops 
of vesicles. A relapse may take place." 

Etiology. — " The disease is seen in both sexes, but more frequent- 
ly in the male. It appears among adults from twenty to thirty years 
of age. It is more frequent in spring and autumn ; coid and 
variation of temperature have a marked influence on its appearance 
and course. Finally, it is always seen amongst people who have had 
still symptoms of gout." 

Nature. — " Hydroa vesiculeux," says Bazin, in continuing his 
description, which we have given above almost at length, " is essen- 
tially arthritic — at least, we have always found it among arthritic 
subjects, and it has steadily presented clear relation to gouty mani- 
festations." 

Prognosis. — " This affection is not grave ; it disappears of itself 
in four or five weeks. It is subject to recur." Bazin treats it by 
prescribing alkaline baths and employing hygienic means, a soft 
diet, and diuretic drinks. 

Hydroa vacciniforme is the same, only that the vesicles are 
varioliform. 

Hydroa bulleux (pemphigus with little bullae) u is an arthritic 
affection which is generally little known. Since our attention has 
been drawn to this point," says Bazin, " we have observed three 
cases of pemphigus with ' small bullae.' " 

" The eruption shows itself by bullae, which present one im- 
portant character — the inequality of their size. Some are as large 
as a lentil, the largest do not go beyond the size of a pea. These 
bullae'are rounded, arranged in an irregular manner, in groups of 
three or four, they are filled with transparent fluid, which grows 
thick quickly and takes a yellowish colour ; finally they are placed 
on a red surface, which extends from their base in the form of an 
areola. Whilst new bullae are developing, the old ones dry up and 
are replaced by a yellowish scab ; and if one of these is rubbed off 
by scratching there appears a violet-coloured, slightly excoriated 
surface. In the interval of the crops of bullae there is no morbid 
phenomenon observed except the ordinary well-marked itching. 
The patient preserves his appetite, and the nutrition is not at 
all altered." Bazin states that the course is chronic, that the 
disease appears in successive crops, and lasts generally from five 
to six months ; that it is more frequent in men than in women, and 
appears in adults from twenty to forty years ; that the seasons and 
variations of temperature have a marked influence on its develop- 
ment ; that it is most common in the spring, and is excited by gout. 

Speaking of Diagnosis, Bazin says : " The characters of hydroa 
bulleux permit always of its being recognised. It cannot be con- 
founded with pemphigus; it is important to establish well the 
differential diagnosis between these two affections, which have not 
always the same origin, and which do not appear of the some 
gravity. In hydroa bulleux the bullae are small, and do not go 



218 BULLOUS EKUPTTON. 

beyond the size of a pea ; they are further remarkable for the 
inequality of their size, they occupy regions sufficiently well cir- 
cumscribed. The bullae of pemphigus are larger — they may attain 
the size of a nut or even of a hen's egg ; they exist in various 
parts, and extend sometimes over the chief part of the skin. Final- 
ly, hydroa bulleux terminates by recovery after a duration of four 
to six months, whilst death is the termination of pemphigus in the 
great majority of cases." I confess I am totally at variance with 
Bazin in reference to these latter statements. 

It will be evident that these cases of hydroa of Bazin are merely 
instances either of herpes or ill-developed pemphigus. Differences 
in the size of the bullas afford no ground for distinguishing the 
eruption from pemphigus. The following account of hydroa, quoted 
by the Amer. Journal of Syph. and Dermat., tells the same tale : — 

" This disease, an old one perhaps re-named, has lately been 
very fully described in the British Medical Journal* It would 
seem from its clinical history that some cases present appearances 
peculiar to it alone, while others show resemblances to diseases 
otherwise named. The diseases which it in a measure resembles 
are, urticaria and the various forms of erythema, and perhaps 
mistakes might be made between it and the vesicular syphilide, 
varicella, and variola. As a rule, it has a definite duration, and 
disappears spontaneously in a few days, and may be accompanied 
by slight fever. The first phenomenon noticed is a faintly-marked, 
rosy spot, which is soon replaced by a single vesicle, which may re- 
main intact or may become ximbilicated, or may dry up and become 
an umbilicated crust of a yellowish-white colour. Around this vesi- 
cle inflammatory changes very soon take place; a zone of a colour 
varying from red to violet, with a well-defined, slightly elevated pe- 
riphery, forms, and. then around tl as perhaps a ring of small vesi- 
cles, which may coalesce and form a circumferential bulla. These 
spots vary in size from a line to four or five, or even more. There 
is no hypememia between the patches, as the inflammatory action is 
sharply confined to them. This condition differs from that of herpes 
phlyctenodes, in which the inflammatory areola is not thus sharply 
defined. There is usually no pain or itching, merely a little heat 
or a feeling of tension. The same appearances, somewhat modified, 
have been observed upon the buccal mucous membrane. The erup- 
tion disappears by the fall of the crust, which is formed from the 
vesicle, and is generally seen in the centre of each patch, and then 
there remains a more or less well-marked hyperemia with slight 
infiltration. The sites of election are the back of the hands, the 
forearms, face, neck, and also the trunk and lower limbs. It is 
genernlly symmetrically developed." 

If the reader will turn to my description of herpes iris, he will 
notice that the characteristic features of that variety of herpes are 

* May 14, 1870. 



BULLOUS ERUPTION. 219 

reproduced in the above description of hydroa, and particularly in 
the words I have italicized. 

But with a view to afford the reader a clearer insight into the 
character of these unusual forms of pemphigus and herpes, I will 
just sketch the features of several varieties or phases of eruption, 
accompanied by the development of bullae, which I have noticed 
from time to time in practice. 

In the first place, the practitioner may meet with cases in which, 
with or without some slight antecedents malaise, or pyrexia, a few 
scattered spots answering as regards eruptive features to Bazin's 
hydroa vesiculeux occur — that is to say, a few red irritable spots 
appear, having in the centre a small oval or roundish bulla, which 
may enlarge to the size of a split pea, but is generally not so large, 
and dies away in the course of a few days. I have noticed these spots 
not only on the back of the hands, but the arms, the legs, and the 
shoulders. The disease may last, by the development of successive 
crops of solitary vesicles, for ten days or more. I suppose it is 
the hydroa vesiculeux of Bazin. 

The more exaggerated form of this disease is that in which small 
bullae are developed rapidly over a large extent of surface, or even 
the whole body. I have at the time of writing under my care a 
boy, eleven years of age, who has suffered from recurrent attacks 
of bullae all over the body at intervals of several weeks. Oc- 
casionally an attack will be composed of two or three successive 
crops, which develop at interval of a few days. The eruption is 
accompanied by much irritation : it is composed of isolated bullae 
the size of a small split pea, or less, scattered all over the body, 
and the bullae leave behind pigmentary stains. The disease would 
answer to Bazin's hydroa bulleux, only that it is more general; 
but it is, I think, a pemphigus with small bullae. 

One of the last cases of the kind, in a less marked degree, I 
witnessed was in a well-known classical scholar, of mature age, 
who had become depressed by over-work. He had on the top of 
the right shoulder a patch of eruption made up of six or seven 
distinct little bullae seated upon a slightly erythematous base, and 
assuming the characters and running the course of a patch ot 
herpes. On the front of the chest were two little patches, the one 
made up of three bullae, the other of two bullae the size of the 
smallest split pea, seated on a reddish base. Scattered over the 
limbs, forearms, and thighs were a number, about eight or nine, small 
bullae, each one being separate. These little bullae varied in size 
from that of a pin's head to that of a split pea. The disease dis- 
appeared in the course of a week or ten days. The patient was 
suffering also from eczema of the legs. The general health was 
fair, and the gentleman suffered only from general debility. 

The features of this case combined those of both herpes and 
abortive pemphigus. 

But the similarity of cases of the kind under notice to herpes, 



220 BULLOUS ERUPTION. 

and herpes iris especially, on the one hand, and pemphigus on the 
other, was exhibited still more clearly in other cases which have 
been under my care. I may mention one case in particular. A 
lady, aged twenty-three, who had just returned from India, con- 
sulted me in December 1872. She told me that her disease began 
in 1870 with an attack of herpes of the face, after a nine months' 
residence at Singapore, and after she had had a sharp attack of 
" Penang fever," which reduced her much, and which hung about 
her off and on for a year, though the acute attack itself passed off 
in a week. The herpetic eruption of the face showed itself on and 
off for a year, and then a patch of disease appeared on the inside 
of the left thigh, and consisted in a redness with little bladders 
upon it (Nov. 1871). As she was leaving Singapore, which is 
relaxing and malarial, the eruption showed itself in different parts 
of the arms and legs, and subsequently appeared en the chest and 
back. On board ship, between Ceylon and Aden, on her way 
home, she suffered from " quotidian " fever. She had already 
taken a good deal of arsenic and iron. When I saw her there was 
scarcely a single inch of her body from head to foot, including her 
face, hands, and feet, which was not dotted over with bullae of the 
most varied sizes. Some were of the size of pins' heads, and often 
grouped together, after the fashion of herpes ; some were as large 
as pigeons' eggs, and could not be distinguished from those of 
ordinary pemphigus. The patient was hysterical, exceedingly low, 
and complained of shivering (? from the pain), and of intolerable 
burning and itching at times. The individual bullse disappeared 
by resorption of their contents or the formation of scabs, and the 
drying up of the reddened surface beneath ; but every few days 
fresh crops of bullse appeared. Under the influence of large doses 
of assafoetida, quinine and iron, wrapping in oil, and the application 
occasionally of a calamine and weak carbolic lotion, this, the most 
curious and severe case of bullous disease I have ever seen, 

ot well, and with it disappeared the tendency to " periodic fever." 

"he lady is now quite well. 
This case reminded me closely of that of the boy of eleven years 
before described, except that it was more exaggerated in all its 
features. 

In some instances in which this quasi-herpetic or pemphigoid 
disease makes its appearance the eruption is preceded by an unusual 
amount of irritation, and it is complicated or followed by true 
pruriginous rash. This is very probably the disease termed pem- 
phigus pruriginosus. Two very remarkable instances of this 
came under my care in the year 1870. In the one the disease 
supervened to an attack of ringworm of the body, the irritation 
from and scratching for the relief of which seemed to be the 
exciting cause of the disease.* The other came on idiopathi- 

* See Lancet, p. 522, Sept. 22, 1871. 



? 



BULLOUS ERUPTION. 221 

cally in a man who had gone through much anxiety and worry. 
The following were the peculiarities of the two cases. The disease 
was symmetrical, and the eruption appeared in the following parts 
— the points of the elbow, and just above it on the back of the fore- 
arm, over the back of the ulna, the calves, the part of the buttocks 
the patient sat on, over the angles of the scapulae and the points of 
the shoulder — in fact, the prominent parts of the body, which bear 
the most friction or pressure. The limitation of the disease to 
these parts in my two cases was most peculiar. The eruption con- 
sisted of little bullae, four, five, or more, seated upon a reddish base 
of the size of a shilling or more, the size of the bullae being larger 
than those of herpes and less than those of ordinary pemphigus. 
Before the bullae appeared there was smarting for half an hour 
or so, which deepened into intense irritation, to be relieved 
by the development of the bullae. The bullae died away, or they 
scabbed over and burst in a day or two, leaving behind little 
solid papules of pruriginous character. There were successive erup- 
tions of bullae, the area of the disease became after a while generally 
thickened, darkly pigmented, and knotty from the development of 
solid, fleshy, itchy papules. Sleep could not be obtained on 
account of the irritation which came on at night. There were no 
rheumatic or neuralgic pains about the body. Excitement or 
fatigue seemed to determine an outburst of eruption and to in- 
tensify the itching. The patients were, however, pallid, fagged, 
and overworked. In one case a spot on the leg like pemphigus 
showed itself. There were no wheals. jSTow I take this disease to 
have been the same as that above described, localized to particular 
regions, and accompanied by the development of prurigo in the 
seats of the bulloid eruption, and it answers to the term pemphigus 
pruriginosus. 

I may therefore sum up the foregoing remarks by saying that 
there is a form of disease which seems to stand midway between 
herpes and pemphigus, the features of which ally it, now to herpes, 
now to pemphigus. It may consist of solitary small bullae seated 
on a red base, and scattered here and there over the body (hydroa 
vesiculeux), or the bullae may be surrounded by small vesicles 
(herpes iris) ; or these two dispositions of the bullae may be seen in 
one and the same case, the eruption being localized to a certain 
part of the body, or generally distributed and accompanied in 
severe cases by pyrexia and marked constitutional disturbance, 
when it is often the result probably of malarial poisoning. The 
eruption may recur more or less periodically ; and lastly it may be 
complicated or followed by prurigo, and in that case will answer to 
the designation of pemphigus pruriginosus. 

In thus describing clinically these unusual forms of " bullous " 
disease, I have attempted to class them as forms of well-known — 
that is, under recognised forms of — eruption, because of the unde- 
sirability of making new designations. I entirely object to tho 
use of the term hydroa as applied to these varieties of eruptions. 



222 BULLOUS ERUPTION. 

I think they may fairly be taken as forms of herpes iris and pem- 
phigus pruriginosus. 

Pathology. — Now as to the pathology of these unusual forms of 
bullous eruption. The nervous system must be directly concerned 
in their production. It is essentially in the overworked, the 
fagged, the depressed, the excited, that these eruptions occur, and 
I imagine they result from vaso-motor disturbance, but nothing 
delinite is known about them. 

Diagnosis.— -The characters I have given are sufficient for diag- 
nostic purposes. The only disease with which they might be con- 
founded is urticaria bullosa, and I do not know that any mischief 
would accrue to the patient from such a mistake. 

Treatment. — This in my hands, even in the worst cases, save 
those that are pruriginous, has been very satisfactory. My first 
care is to attend to the general condition of my patients as regards 
their emunctory organs and their hygiene. Anxiety, worry, and 
depressing influences must be neutralized. The patient must be 
ordered to get good air, to take plain nourishing food, and to avoid 
luxuries of the table, overwork, and fatigue of all kinds. 

Anaemia should be carefully attended to, and remedied by iron 
preparations. 

The main general remedy in all these cases, according to my 
experience, is quinine. It should be given in from two, for mild, 
to ten-grain doses, in severe cases, and it will generally succeed 
in checking speedily and vanquishing the disease. But local mea- 
sures are of no little importance. I am in the habit of employing 
alkaline and bran baths at the outset, of applying either simple oil, 
or a lotion containing oxide of zinc and levigated calamine powder, 
and, if the parts are much excoriated, of subsequently dressing the 
sores with benzoated zinc ointment, or Kirkland's neutral cerate. 

In the pruriginous variety of the disease, intense difficulty is 
occasionally experienced in curing the disease, and this requires all 
the tact and skill that the physician can bring to bear upon the 
matter. The hygiene, diet, and general surround ings of the patient 
are of great moment, in so far as they influence the general 
health of the patient; and iron, mix vomica, cod-liver oil, and 
quinine may be -severely needed in different cases, according as 
the indications present are those of anaemia, nervous debility, 
wasting, neuralgia, or periodicity. I have found at the outset that 
diuretics — any that act efficiently will do — freely given, do much 
good in relieving the hyperaemia of the skin. If the disease occurs 
in the gouty, I have given colchicum with benefit, but not without 
combined tonics. 

Locally I know T of nothing better than first of all, vapour baths, 
to encourage the skin to proper action, and the use of a weak lotion 
made of liq. carbonis detergens 3 ij to 1 ss with aquae 1 vj applied 
night and morning. Subsequently sulphuret of potassium baths 
may be regularly given for a long time, and followed up by the 
drinking of some sulphurous or iron waters. 



223 



CHAPTER XII. 

SUPPURATIVE INFLAMMATION, OR PUSTULAR DISEASES— IMPETIGO- 
CONTAGIOUS IMPETIGO— ECTHYMA— FURUNCULUS— ANTHRAX, OR 
CARBUNCLE-MALIGNANT PUSTULE— DELHI BOIL— ALEPPO EVIL 
—BISKRA BOUTON. 

General Remarks. — In many very different diseases of the skin 
pus is present, and if the term pustular were used in its widest 
sense, a large number of diseases would have to be included under 
it ; for instance, acne ; parasitic diseases, such as favus and scabies ; 
pemphigus; variola; farcy; varicella; and so on. But in the 
diseases just named the presence of pus is often not a primary or 
even essential condition, and its importance is thrown into the shade 
by the prominence of other features. In those affections which 
may more strictly be called pustular, the suppuration is the leading 
and the primary condition, the particular morbid condition the 
practitioner has to recognise and to remedy. Now nnder the term 
pustular diseases, thus defined, are usually comprised impetigo, 
ecthyma, and furuncular affections — the latter term including furun- 
culus, or boil ; anthrax, or carbuncle ; and pustula maligna, or ma- 
lignant pustule. I shall also refer nnder this head to Delhi boil, &c. 

IMPETIGO.* 



In describing eczema it was statod that in some cases instead 
of the secretion remaining sero-plastic, it became charged with 
pus-cells — in fact, sero-purulent or puriform. The variety in which 
this occurred is called eczema impetiginodes (pustular eczema). 
If this purulent character be assumed from the first, then the 
disease has been called impetigo. Most authors agree in regarding 
impetigo as a pustular eczema — an eczema occurring in a pyogenic 
habit of body. I may therefore rank it with eczema ; and I "refer 

* Impetigo Rodens. — Under this term have evidently been included many 
different diseases. Hardy calls the affection scrofulide pustuleuse. The disease is 
said to occur about the sides and tip of the nose, first as small pustules on a red 
base, that break out into ulceration, and are replaced by a brownish scab, which 
covers over a dirty foul ulcer. This I take to be a syphilitic disease and nothing 
more. But impetigo is moreo-ver a superficial pustulating and non-ulcerating 
affection ; the word rodens signifies an " eating out," and it is most probable that 
by I. rodens has been meant now a syphilitic, now a scrofulous ulceration. Tne 
disease finds no place in my work. 



224 IMPETIGO CONTAGIOSA. 

the reader to that disease for a description of ordinary impetigo. 
I discard the term impetigo, in fact, for any other disease than the 
one I am now about to describe under the name of 



IMPETIGO CONTAGIOSA, OR CONTAGIOUS IMPETIGO. 

This, at times a common form of cutaneous disease, is seen 
especially in dispensary and hospital practice. It is universally 
classed by practitioners with eczema impetiginodes or impetigo 
simplex, but yet it is, as regards nature and characters, a wholly 
distinct affection. I first described it as a separate disease in 
1862. Its cure is usually certain and easy by local means. It is 
classed under the term porrigo, as used by some writers, and is 
one of the many varieties of eruption which together constitute 
the composite " scald-head." I have hitherto called the disease 
contagious impetigo ; for it is essentially inocnlable (contagious), 
but I am quite prepared to accept a better name. The disease is 
often quasi-epidemic ; it differs in severity and in features at dif- 
ferent times, tends to run a definite course, but it exhibits a uni- 
formity of character as regards the eruptive condition, and is 
vesico-pustular in type. I have had the pleasure of convincing 
not a few of the distinctness of this form of disease; and recently 
Dr. H. W. Taylor,* of New York, has recorded cases under his 
care, whilst the existence of the disease is now allowed at Yienna 
even. 

Clinical History. — The disease is seen amongst children of the 
lower orders especially, probably in great measure because the 
disease spreads by contagion freely amongst them. It occurs also in 
those who have cell the advantages of social position and good hygiene. 
It is ushered in occasionally by smart, generally by slight, fever ; 
or the child looks ill, pale, languid, and is said to have been " in 
a burning heat," or to have had " cold chills." There is clearly 
an affection of the system at large before the occurrence of any 
eruption. In the summer of 1870 I had a large number of cases 
under my care at the hospital, and in many instances there was 
snlart pyrexia accompanying the development of the disease. 

The eruption in the disease in the majority of cases appears 
first of all on the face, sometimes on the top or back of the head, 
and in the form of " little watery heads " (vesicles), that enlarge 
into flat bullae if they are not injured by scratching. Sometimes 
the hands are attacked at the outset, and look as if burnt here and 
there ; phlyctense may also arise out of and around the remnants 
of vaccinia, or about cuts or bruises. The disease then extends 
to other parts, the back of the neck, buttocks, feet, &c. The 
vesicles are always isolated. In five or six days the bullae may 

* Amer. Jour, of Syphilography and Dermatology, Oct. 1871, p. 368 ; and Boston 
Med. and Surgical Journal, June 6, 1872. 



IMPETIGO CONTAGIOSA. 225 

reach the size of a sixpence or shilling unless ruptured, and are 
then flat and depressed in the centre, their contents becoming turbid. 
Usually the vesico-pustule is the size of a large split pea or there- 
abouts. The secretion consists of lymph-like fluid, granular cells, 
and subsequently pus-cells. 

Scabs commence to form a few days after the appearance of the 
disease. They are characteristic of the disease, varying in size 
from that of a split pea to a shilling ; they are flat, straw-coloured, 
dry, and granular-looking, and appear as if " stuck on " to the 
part ; they present, as a rule, no inflammatory areola around their 
circumferences, though this is the case in severer instances of the 
disease. If removed, little sores are observed beneath, more or 
less filled in by gummy-like secretion, or a little pellet of aplastic 
lymph, and when the scabs fall off there is an erythematous base 
left behind, the hue of which gradually fades away. The disease 
may be spread from spot to spot by direct inoculation with its 
secretion, in the act of scratching. The crop of vesicles is to 
some extent successive, though the majority of the places "come 
out" in the first week or so. In some instances the disease re- 
sembles vaccinia very closely. There is always a uniformity about 
it ; it always commences by vesicles ; there are no papules present 
at the height of the disease. On the face the spots may be con- 
fluent, and then the disease resembles eczema impetiginodes ; but 
the patches are made up of the elements described above. On 
the scalp the disease consists of circular, mostly isolated, flat- 
scabbed spots about the top and back of the head, the hair being 
matted by the crusts. Usually, no pediculi and no offensive smell 
are present. Xow it is very important to note that an eczema 
may be readily excited in fair children by scratching or the irri- 
tation of the discharge, in connexion with impetigo contagiosa — 
and then the characteristic features of the latter disease are 
masked. The result of neglecting to attend to this point is that 
the practitioner regards the disease present as solely and entirely 
an eczema. The error, too, is a very common one. 

The mucous membranes of the eye and the nose are sometimes 
implicated ; then inflammation is produced by the development of 
little ulcers, that take their origin in the formation apparently 
of vesico-pustules, identical with those seen on the surface of the 
skin. The eye may look as though affected by slight purulent 
ophthalmia, but soon recovers itself. 

Many children in a house may be attacked by contagious im- 
petigo at one and the same time, or consecutively, and in such 
a way as to impress upon even friends and attendants the idea of 
its being contagious. The disease may complicate eczema, scabies, 
and other affections, and vice versa. 

I noticed in the quasi-epidemic of 1870, of which I spoke before, 
how completely the definite course of the eruption was masked by 
the successive cropping-up of fresh places, in part induced by the 
15 



226 IMPETIGO CONTAGIOSA. 

inoculation from scratching ; and also by the fact that the patient 
scratched open the pustules before the scabbing had taken place, 
and so prevented their drying and healing up. The general answer 
to the question, " How did it begin % " was, " By a little watery 
head." Some parents stated that they "thought it was a pock;" 
others that "it looked like horn-pock;" but all declared that it 
commenced by separate vesiculations, which enlarged, if left undis- 
turbed, into bullae, and were replaced by scabs. In this respect 
the disease differed entirety from ordinary impetigo. The face was 
the part most usually attacked, but also the hands, head, and limbs. 

I have again and again reproduced the disease in others by 
inoculation, and in all cases the resulting disease was typical ; it 
was, unlike ecthyma, superficial, and the vesico-pustules were 
formed in the rete. 

It has been asserted by some — Moritz Kohn of Vienna, and 
Dr. Piffard* — that the disease is parasitic. This was was one of 
the very first points that I took care to investigate when I origi- 
nally studied the disease as a separate skin affection. I could, as 
have these gentlemen later on, detect fungus elements in the crusts, 
but not in the fluid contained in the vesico-pustide before this bursts. 
The fact of finding fungi in the crusts is explained by that of the 
access of air to the layers of the crust. In the first place, in order 
to show that the presence of the fungus is something more than 
an accident, it would be necessary to discover the fungus in the 
fluid of the vesico-pustule before it bursts. But the whole character 
and course of the disease, with its febrile disturbance, its vesico- 
pustular aspect, the definite course of each vesico-pustule like that 
of an herpetic vesicle, and the like, are utterly unlike those of a 
parasitic disease. The disease is certainly not parasitic, and I 
think my opinion on the point is of some little value, since of all 
dermatologists I am perhaps the one most firmly wedded to the 
conviction that parasitic growths are potent producers of mischief. 

Diagnostic features are — its apparently epidemic character in 
many cases ; the antecedent febrile condition ; its attacking 
children ; the origin from isolated vesicles, which tend to enlarge into 
blebs and to become pustular, the bleb having a depressed centre, 
and, it may be, a well-defined, slightly raised, rounded edge ; the 
isolation of the spots : the uniform character of the eruption, and 
its general and scattered condition; its frequent seat and com- 
mencement about the face or head ; the circular, flat, granular, 
yellow crusts looking as if stuck on ; its contagious nature and 
inoculability ; its frequently following in the wake of vaccination ; 
the absence of pain, and especially troublesome itching at night. 

Contagious impetigo may be confounded with eczema ; but the 
history is altogether different, and the isolation, the small scabbed 
patch, the characters of the crusts, and the facility of cure, at once 

* New York Med. Journal, June, 1872, p. 62a 



ECTHYMA. 227 

distinguish it. Impetigo sparsa does not arise from a vesieulation, 

but is primarily pustular, made up of aggregated pustules ; it is 
not phly ctenoid ; it is not contagious nor inoculable ; it does not 
run a definite course ; it is not confined to the young ; it is not so 
amenable to treatment. Pemphigus. — In this disease the blebs are 
larger, more persistent, oval, and distended ; the contents are watery 
and acid. Pemphigus is non-contagious ; it does not occur espe- 
cially on the face or the head ; it is less inflammatory, and wants 
the characteristic scabs. Ecthyma. — This is primarily a pustular 
disease ; it is seen also in adults ; there are more induration and 
swelling, and a good deal of pain in connexion with the formation of 
pustules ; it is non-contagious ; the scabs are heaped-up and dark. 
Pustular scabies. — This is the disease with which contagious im- 
petigo is at times confounded. It must be remembered that the 
two diseases may co-exist. In children both attack the buttocks 
frequently; both may exist about the hands and feet; but the dis- 
tinctions are really very clear. In scabies there is no febrile con- 
dition; the eruption is multiform. If there be ecthymatous pus- 
tules, like impetigo contagiosa, they are covered by dark thick 
crusts ; there are plenty of characteristic vesicles, with cuniculi 
and papules. If the imjietigo contagiosa begins about the but- 
tocks, it appears presently on the face or the head, or both. There 
is no irritation, nor are the effects of scratching visible about the 
body as in scabies ; the bullous origin of the disease is distinct, 
and the scabs are characteristic. The bands are not specially 
affected in scabies in the child, but even impetigo contagiosa may 
attack the hands and feet markedly; still there is no multiform 
eruption, and there are no cuniculi in the latter. 
. \Yhen a correct diagnosis is made, the treatment is easy. The 
natural go urse of the disease is a short and definite one. The disease 
sometimes occurs in badly-hygiened subjects, and therefore tonics 
may be required. The secretion is an active agent, by means of 
inoculation self -practised by the patient in scratching, in transmit- 
ting the disease from one part to another. Therefore it is of first 
importance to destroy the activity of the pus, and to alter the 
behaviour of the surface that secretes it. I invariably use an 
ointment containing five grains of the ammonio-chloride of mer- 
cury, and apply it to the surface beneath the scabs, which I cause 
to be removed by poulticing or fomentation with warm water. 
This rapidly cures the disease. 

ECTHYMA. 

This disease is described as consisting of isolated phlyzacious 
pustules — viz., those which are " large, raised on a hard base, of 
a vivid red colour, and succeeded by thick, hard, dark-coloured 
scabs, beneath which there is ulceration." The pustules are gene- 
rally distinct, round, and isolated ; they are mostly general, but 
may be partial, and leave cicatrices behind. The shoulders, but- 



228 ECTHYMA. 

tocks, and limbs are the parts usually attacked. There are two 
chief forms described in books — acute and chronic. 

Now, as a matter of fact, acute general ecthyma is rare, but I 
have seen it. The ordinary scattered ecthyma is practically always 
the result of the action of some irritant upon the skin, in an 
unhealthy or badly nourished subject; and so ecthymatous pus- 
tules frequently occur in connexion with scabies and phtheiriasis, 
and more rarely prurigo, eczema, and other diseases. 

I will describe the acute and chronic forms in detail. 

Acute ecthyma commences with slight febrile disturbance, and 
occasionally sore throat ; locally, there is first a sense of heat and 
burning, followed by the appearance of reddish raised points, with 
hard indurated bases, and distinct vivid areolae; these points, which 
vary in size from that of a pea to that of a shilling, quickly pustu- 
late, and are often accompanied by acute, sharp pain. In two or 
three days the pustules give exit to discharge, which dries into 
hard, adherent, dirty, discoloured scabs, covering over circular 
ulcerations: the crusts fall off in a week or so, leaving behind 
dark stains. The ecthymatous spots may be many or few ; in the 
former case a good deal of irritation is set up : the patient may 
be unable to sleep from pain, and the glands and lymphatic vessels 
may become inflamed, small abscesses forming subsequently. The 
disease is generally protracted by successive crops of pustules, or 
it may relapse into a chronic state. The limbs, shoulders, and 
trunk are the chief seats of the disease. 

This acute ecthyma is a great rarity in my experience, and I am 
by no means indisposed to regard it as the result of syphilis ; 
though I am not sure that it may not occur from general debility 
in badly nourished persons. 

Chronic ecthyma, as before hinted, generally results from the 
action of some irritation, as in scabies, in connexion with pediculi, 
and from scratching in badly nourished subjects. It has been 
usual to describe three varieties : E. infantile, luridum, and cachec- 
ticum. There is no need to make such varieties; of course 
when an ecthymatous pustule develops in a cachectic subject, it 
may slough or ulcerate, and it is the occurrence of such a circum- 
stance that is intended to be brought to notice in the use of 
the two latter terms. The so-called E. gangrenosum is rupia, 
and nothing more. 

The ecthymatous pustules in the chronic disease are of similar 
characters to those of acute ecthyma. They are painful, with 
hard, inflammatory bases and a small central collection of pus. 
When they occur on the limbs, especially the legs, in old people 
they are followed sometimes by troublesome ulcers. 

Pathology. — In ecthyma the seat of disease appears to be the 
uppermost layer of the derma, not unlikely about the glands of 
the skin, the depth of surface involved is less than in furunculus, 
and there is no " core," otherwise ecthyma would be well classed 



ECTHYMA. 229 

with boils. The tendency to ulceration and sloughing, the lividity 
of the inflammatory areola, the disturbance of the general system, 
all point to a cachectic condition. 

Causes. — The predisposing causes are always such as lead to 
debility and an impoverished state of blood. They are, in infants, 
bad nursing, suckling by mothers much out of health, scabies, bad 
clothing, damp dwellings ; in adults and others, over-work, fatigue, 
convalescence from acute diseases, bad food, privations, various 
occupations that induce irritation of the skin — ex., bricklaying, 
excesses of all kinds, debauchery, uncleanliness, night-watching, 
overcrowding in public institutions — ex., workhouses, jails, hos- 
pitals, and such like. The immediate exciting causes are scabies, 
phtheiriasis, the use of acrid medicinal applications, and empha- 
tically scratching. 

Prognosis is to be made according to the general condition of 
the patient. The ecthyma, per se, is of little gravity, save when 
it is accompanied by sloughing, as in old people; then it is 
grave. 

Diagnosis. — The distinct, large, isolated pustules, with an in- 
flamed areola and hard base, distributed over the body, are very 
distinctive of the disease. It may be confounded with Impetigo 
sparsa, but in this disease there are rather sero-pustules than pus- 
tules, which are very superficial ; the discharge is viscid, yellowish, 
there are no dark scabs, no indurated, inflamed, and painful 
bases. FuruncuXus is deeper, it runs a slower course, and contains 
a central " slough " or " core," as it is called. It is more circum- 
scribed, and there is little scabbing. 

Treatment. — It is necessary to recollect, in the first place, that 
ecthyma is a cachectic disease : that it often occurs in those in 
whom the eliminating organs are sluggish, and in whom, moreover, 
effete material has been largely produced in the system : and 
in the second place, that it is either primary or secondary — as, for 
example, when it occurs in connexion with scabies or phtheiriasis. 
When it is secondary to other diseases, or if it arise from the action 
of local irritants upon unhealthy skins, as from the contact of lime 
or sugar, one has only to remove these sources of evil, and 
use soothing remedies with astringents — alkaline lotions, or 
glyceral tannin, or biborate of soda or zinc ointments — and give 
internally iron, mineral acids, or other suitable tonics, for the case 
to get well. Supposing there is no external cause of this kind, 
the impoverished state of blood which gives rise to the disease 
must be treated. I am of strong opinion that elimination first of 
all needs attention. In young subjects, active aperients together 
with tonics are the best remedies. After a good colocynth purge, 
the exhibition of a mixture containing sulphate of magnesia, sul- 
phate of iron, tincture of calumba, and cinnamon water, or if the 
appetite is bad, dilute nitro-hydrochloric acid with sulphate of 
quinine, and infusion of roses, soon improve the whole 



230 FURTTNCTTLAE AFFECTIONS. 

tone of the system. At the same time the patient must eat 
wholesome food, get proper rest, and a proper amount of air in 
his sleeping- room ; and it is of much importance that he be cleanly, 
and not over-worked. All these are material points in the treatment. 
If the patient be young and growing, he. must be particularly 
well-dieted, have a good amount of wine or sound beer, and take 
cod-liver oil. Locally, in ecthymatous cases, where .the disease is 
idiopathic, emollients are alone admissible in the early stages — 
warm lead lotion and poppy-head fomentations. Presently, opiate 
and tannin ointment — extract of opium, ten to twenty grains, a 
scruple of tannin, with an ounce of simple ointment may be em- 
ployed, and finally the remedy so much in vogue on the Continent 
for boils — the emplastrum fuscum (see Formula 140) may be used. 
I trust to the general and not the local remedies. But there is still 
the chronic form of ecthyma to deal with. Even here I lay great 
stress on a sufficiency of aperients, and on the mineral acids, 
with bark, and bitters of all kinds. If there be much nervous 
disturbance, pain, restlessness, and the like, opiates judiciously 
exhibited are of service ; change of air will sometimes work won- 
ders, and in the cachectic varieties, good living — plenty of meat and 
wine — with bark and ammonia, must needs be given. And locally 
in chronic ecthyma the scabs should be removed, and attempts 
made to get clean and healing surfaces by the application of 
w T eak Condy's fluid, weak carbolic acid lotion, simple sulphur 
ointment, or weak nitrate of silver lotion, when stimulation is 
necessary. If there be much irritation, lead and opium lotion, or 
charcoal dressings, may be of service. A good application is an 
ointment made by rubbing together an ounce of lard, and half a 
drachm or so of Friar's balsam. 

Iso two cases of ecthyma are exactly alike, and the special 
knowledge of the physician is often needed to detect some flaw 
in the performance of the organic functions which mainly de- 
termines the occurrence of the disease. 



FURUNCULAR AFFECTIONS. 

There are several varieties of eruption classed under this head. 
Common boil or furuncle, carbuncle or anthrax, malignant pustule, 
together with Delhi boil, Aleppo evil or boil, and Algerian boil or 
Biskra bouton, make up the list. 

It has been said that furuncular affections differ from impetigo 
and ecthyma, by, amongst other things, being deeper, and by their 
pustules containing in their centre a dead piece of tissue which is 
called the " core," in fact a central " slough." Now this " core " is in- 
deed the essential feature of a furunculus ; its nature will be noticed 
by-and-by. Furunculus or boil, and anthrax or carbuncle are forms 
of one and the same disease. Malignant pustule is produced by a 
specific poison, and should be ranked elsewhere. The general eha- 



OR STY. 231 

racteristic then of f urunculai* affections is the occurrence of inflam- 
mation of a limited extent, affecting the tissues deeply, the central 
part dying and forming " the core." Some think this core is a true 
exudation, some a piece of " dead cellular tissue." When a boil is, so 
to speak, multiple, when there are several " cores," and the cellular 
tissue is much involved, and more or less sloughy, then a carbuncle 
exists. But, to put it in text-book language, "the characters of 
distinction " between furunculns and anthrax relate to their promi- 
nence, depth, breadth, colour, number of cores, and degree of 
pain. Furunculns is a solitary pustulation, it is more prominent, 
less deep, involves less of the tissues around, has a deep red areola 
which assumes a bluish tint after awhile : the " core " is single, and 
the pain is less severe. Anthrax is less prominent, it is deeper, 
involves more tissue, is much darker in colour, possesses many 
" cores," and is accompanied by greater pain. But the differences 
are in degree, not in kind, of tissue involved. I will first give the 
general features of furunculus and anthrax, and then comment on 
their pathologies and therapeutics together. 

FURUXCULUS, OR BOIL. 

The general symptoms are as follows in some cases: — Febrile dis- 
turbance, rigors, loss of appetite, headache, and disordered bowels. 
Locally, a little red lump, the size of a split pea, makes its ap- 
pearance: it is tender, painful, and tense, and soon becomes in- 
durated. The disease is felt to be pretty deep : a red blush surrounds 
the base of the swelling, and changes from bright red to purple. 
In from three to six days the apex of the boil becomes yellow from 
the formation of pus : the pain is now throbbing, the induration of 
the tissues at the base augments, and so does the amount of pus in 
the centre of the pustule. If left to itself, the " pustule " bursts, and 
presently " the core " comes away. After this has happened, healthy 
granulations at once spring up, and repair is quickly completed. 
In some boils the suppurative stage is scarcely reached, and such are 
named blind boils. Furunculus generally attacks the neck, buttocks, 
arms, especially in young people, and there are successive crops of 
pustules, so that the disease often lasts a considerable time. The 
glands may be enlarged. The pain is severe in boils that occur in 
parts that are dense and cannot swell, as in the meatus of the ear 
and the pudendum, or those that are freely supplied with nerves, as 
the face. 

HORDEOLUM, OR STY, 

Is a small boil seated at the edge of the eyelids and involving a 
Meibomian gland. It is not an active kind of boil, but progresses 
sluggishly, the pustule centre being small. It is painful, and some 
time lapses before all traces of its existence go. There may be one, 
two, or more, on one or both eyelids. 



232 ANTHRAX, OK CARBUNCLE. 



ANTHRAX, OR CARBUNCLE, 



Is a multiple furuncle. It arises as a hot, hard swelling, not so 
conical as that of the boil — more indurated, however, the cellular 
tissue around being much more extensively implicated ; its colour 
is dusky, the sensation burning, dull, throbbing; the carbuncle 
varies in size, the swelling becomes "brawny," from the meshes 
of the cellular tissue becoming filled with a plastic lymph. The next 
step is the formation of a quasi-abscess ; the central part of the 
swelling softens, and feels boggy ; the skin becomes thin over the 
surface, and at several points openings occur, through which slowly 
issues more or less sanious pus ; and the little holes are seen to be 
plugged up by small white cores, which presently loosen and come 
away ; the apertures are red and papillated, the edges indurated 
and everted, particularly when several openings coalesce, so as to 
form one or more large openings. Gangrene may set in. The 
healing process is often indolent, the parts remaining undermined, 
brawny, dusky, shreddy, and also sloughy. Carbuncles are generally 
solitary. The patient, if the attack be severe, gets into a very 
depressed state. The posterior aspect of elderly people is the 
selective seat of carbuncle. 

Morbid Anatomy. — A careful study of the changes that go on in 
the skin in carbuncles and boils is much wanted. The anatomical 
seat of boils is supposed to be the deeper part of the cutis, but it 
seems to me likely that it is essentially the follicles and their attached 
sebaceous glands. In some cases one can very clearly make out the 
opening of the follicle in the centre of furunculi, especially when 
the boil is beginning to form, as in the case of hordeolum or sty, and 
it is only fair to M. Deimce,* of Bordeaux, to state that he has in- 
sisted that the real seat of boils is the sebaceous glands. Some 
authorities (Neumann) f make two seats — the one the hair follicle 
and the other the cellular tissue. In the latter case the boil is 
regarded as a diffuse inflammation of the cellular tissue. It 
may be as Neumann says, but still there is reason to think that 
the original seat of mischief is the portion of the follicle about the 
sebaceous glands. Bindneisch remarks that wherever he has had 
an opportunity of examining the " core " of a boil he has always 
found in it the connective tissue which forms the bed of the hair 
follicle. But he does not say that the disease starts in the deep 
part of the follicle. In boils of large size the connective tissue 
beneath the cutis is involved. Some suppose that in one par- 
ticular region the infiltration by cells and pus is so great that the 
blood-vessels are compressed, and the infiltrated part is cut off and 
separated from the adjoining connective tissue, and cast off as the 

* Des Formes Malignes du Furuncle et de 1' Anthrax, par le Dr. Denuce. (Rapport 
Congres Medicale de France, 3 e session, tenu a, Bordeaux, 1866.) 
\ Handbook of Skin Diseases. 



ANTHRAX, OR CARBUNCLE. 233 

core, which is composed of connective tissue and broken-up cells 
and debris. But it is not at all unlikely I think that the core may 
be a sebaceous gland with attached connective tissue. The glands 
have become pressed upon, strangulated, and more or less dead 
or sloughy. Now it seems that in anthrax there are many 
" cores," the cellular tissue is implicated to a greater extent, 
and sloughing also freely occurs. In comparing together acne, 
ecthyma, and furunculus, some analogy between them is noticed. 
M. Denuce thinks that acne is constituted by hyper-secretion and 
induration, ecthyma by suppuration of the gland and suffusion of 
pus under the epidermis which surrounds its outlet, and furuncle 
is a mortification and elimination of the gland itself ; in fact, that 
in acne there is plastic, in ecthyma suppurative, and in furuncle 
gangrenous inflammation. Of furuncle he thinks there are three 
kinds — simple, phlegmonous, and gangrenous. In the first the 
gland mortifies and comes away as the core, in the second the 
cellular tissue is involved, and in the third the central part mor- 
tifies en masse. If furuncle be confluent, anthrax is produced. I 
confess I fail to see the essential difference between ecthyma and 
furunculus. Ecthyma seems to me to be more superficial, whilst 
no true core is formed. But acne is different. I think that in acne 
the inflammation is secondary to retention of sebum, whereas the 
causes of ecthyma and furunculi are different. 

Pathogeny of Boils, dec — The popular belief is that the " core " is 
the result of a circumscribed gangrene, and many think this is the 
result of a " bad state of blood," or a " debilitated condition of the 
constitution." But there is this to be said in regard to boils as a 
rule, that as soon as the "core" is away, the wound left heals 
readily and perfectly. Now if the "core" is produced by a bad 
state of general nutrition, leading to gangrene or local sloughing, 
how comes it that the healing of the wound, left after the discharge 
of the core, is so vigorously carried on in the face of such a state 
of health ? This doctrine of the mode of production of the core 
supposes that there are two actions of diametrically opposite cha- 
racters — a gangrenous and a vigorously reparative one — going on 
side by side in the same patient. If the primary death resulting 
in " the core " were due to a tendency to gangrene in the 
system, why should there be present in the same subject and 
in the same part a thoroughly satisfactory process of repair % 
What, indeed, is there in the clinical history of boils, or the 
condition of patients affected by them, to account for the spon- 
taneous death of a piece of cellular tissue % If " the core " be 
regarded as an exudation, no analogy exists in support of such 
a proposition. It is clear that the only satisfactory explanation is 
that which recognises that some disorder in the circulation of the 
part first takes place, that the tissues fail to be properly nourished, 
to perform their functions, and then die (slough), and that an 
attempt is made by suppuration to get rid of the moribund or 



234: ANTHRAX, OR CARBUNCLE. 

useless tissue. If it can be shown that the sebaceous glands, 
in the performance of their emunctoiy act, are disordered by 
effete matter with which the blood is charged ; that they are then 
congested and inflamed, then suppurate and die, and with the 
contiguous cellular tissue form " the core," it can be readily 
understood how it can come to pass that healthy reparative action 
is at once set agoing after the dead tissue comes away, and further, 
it is easy to comprehend how it is that friction and irritants of 
all kinds determine the seat and occurrence of boils in those who 
are predisposed to them. A blind boil according to this theory is 
an inflamed sebaceous gland, which happens to recover itself before 
the stage of suppuration has been reached. 

Boils occur where glands are large, where the skin is tough, and 
liable to be injured — ex., the back of the neck, shoulders, and the 
outer side of the limbs, and the boil varies in character and degree, 
according to the depth of the cellular tissue around the gland in- 
volved, and the state of the blood ; boils are large and severe in 
debility after convalescence, in diabetes, albuminuria, and the like ; 
small and painful in young and plethoric subjects. If boils are the 
result of an inflammatory state of the skin glands and adjacent cel- 
lular tissue, their occurrence in full-blooded and apparently healthy 
persons is explained by the action of a state of the blood overcharged 
with the waste products of the body. 

In carbuncles there are similar changes to those in boils, but a 
much severer degree of disease. Here a group of sebaceous glands 
is involved, and in consequence of the more cachectic state of the 
nutrition the reparative attempt is less perfect, the inflammation is 
of a lower type, and the cellular tissue sloughs and dies to a 
much greater extent. The nutrition is not only unequal to prevent 
the local disorder, but also incapable of putting repair in proper 
operation ; and there is one disposition in carbuncular subjects 
that perhaps has a peculiar influence in disposing to sloughing and 
gangrene of the cellular tissue : this is the tendency to, or an actual, 
diabetic habit. This has been exemplified of late by many ob- 
servers — Prout, Goolden, Landouzy, Wagner, De Calvi, Fonseca, 
Menestrel, Klichenmeister, and others. Anthrax is very common 
in Pernambuco, and Fonseca finds it connected with diabetes, or 
a diabetic tendency. Sugar occurs in the pus of the carbuncle, 
and it is a curious fact — so it is stated — that when anthrax de- 
velops, the sugar is diminished or disappears from the urine. 
M. Ye'rneuiP not long since corroborated Wagner's observation 
relative to the occurrence of phlegmonous and gangrenous inflam- 
mation in diabetics in certain cases of gangrene of the lower limb 
occurring in connexion with saccharine urine. 

But I have entirely omitted to show that boils occur under 
conditions in which the blood is impurified or surcharged with 
effete products, which, by circulating through the skin, may irritate 

* LTTnion Medicale, Dec. 1, 1866. 



ANTHRAX, OR CARBUNCLE. 233 

or inflame the glands. In summing up the conditions under which 
boils occur, it will not be difficult to classify the main ones as 
follows: — (1) during seasonal changes in spring and summer; (2) 
from eating diseased meat (frozen) ; (3) when any special altera- 
tion is made in the ordinary habits and economy of the body, as 
in the training of prizefighters ; (I) from the influence of cadaveric 
poisons ; (5) from sudden change of diet ; (6) after fatigue of long 
duration ; (T) during convalescence from debilitating diseases ; (8) 
as a consequence of the action of septic poisons, as in fevers, &c. ; 
(9) in albuminuria; (10) in the diabetic habit; (11) during 
adolescence, and in the first stage of manhood. In most of these 
cases there are " debility " and an overloaded state of system — ex., 
the circulation of urea, of sugar, of septic poison, or of effete 
matter which is plentiful during convalescence ; and it only needs 
the action of some local irritant to determine the development of 
furunculi in the parts to which that irritant is applied. 

Diagnosis of Boils and Carbuncles. — lS"o error can possibly be 
made in respect of these two diseases ; in the former the hard, 
deeply-seated induration, the pain, the central suppuration, and 
the " core," are distinctive. The manifold openings, the boggy 
feel, the sloughing, the grumous discharge, and the implication of 
the cellular tissue in carbuncle are very peculiar. Furunculi are 
sometimes epidemic. 

Treatment. — If the view I have given of the nature of boils be 
correct, then it is not difficult to lay down a satisfactory plan upon 
which to base their treatment. Boils are accidents common to 
many conditions, but produced in all of them from a similar cause — ■ 
viz., a disordered blood condition, with nutritive debility and de- 
ficient elimination in subjects whose tone is lowered. First, with 
regard to boils. There is always deficient elimination in con- 
nexion with them ; it may be in a young and naturally vigorous 
youth who is rapidly growing, and is perhaps hard worked, and 
who does not get quite the right food he needs. If the disease 
assumes what may be fairly called a sthenic form, here saline 
aperients and a modified diet suffice ; but where there is marked 
want of tone, in such a case sulphate of magnesia, infusion of 
roses, and quinine at first, and then cod-liver oil, are the proper 
remedies internally. Again, in those who are breathing a 
vitiated atmosphere — in the dissecting-room, for example — • 
change of air, quinine, aperients, and rest, soon improve the 
general condition; or bark and chlorate of potash, with the 
mineral acids, are equally good medicines. In the case of indi- 
viduals of mature age but good average nutrition, if the emunc- 
tory functions are disordered, it is necessary to aid elimination 
and to tone. If the urine be loaded and the bowels irregular, the 
combination of acetate or bicarbonate of potash with ammonia, 
followed by calumba and an alkali, are advisable. If there be a 
gouty diathesis even colchicum or iodide of potassium are called 



236 ANTHRAX, OR CARBUNCLE. 

for, with tonics. In the case of boils occurring during convales- 
cence from febrile diseases, there is still the removal of waste 
products to attend to, and the necessity for tonics at the same 
time. These remarks mainly refer to young persons. But boils 
trouble middle-aged and elderly folk. In some instances one has 
to deal with careworn and anxious men and women, who have a 
pretty hard struggle to maintain their position, and a good many 
mouths to fill at home, and who are yet essentially healthy and 
sanguine subjects. The diet of these persons has been deficient ; 
it requires to be not only more ample, but more varied, if possible. 
Here again aperient tonics seem to me to be indicated, and I be- 
lieve that opiates (the watery extract) freely given, if there be 
much nervous excitability, will lull the patient, both as regards 
his pain and his depression. Then it is of prime moment that we 
are sure that our patient's gall-bladder is properly emptied. In 
some instances of over-worked middle-aged persons, the sallow 
complexion, the almost actual icterus, the loaded urine, flatulent 
dyspepsia, and want of tone, point mainly to a congested and in- 
active liver as the source of mischief. Such a case demands 
podophyllin in repeated closes, the nitro-hydrochloric acid in- 
ternally with mix vomica, and the careful regulation of the diet, 
together with the avoidance of saccharine matter, pastry, and 
malt liquors. In young women who are naturally of good con- 
stitution, and who get somewhat ansemiated, or have their men- 
strual functions disordered, boils are often seen about the armpits. 
In such cases aloetics and quinine with iron, moderate exercise in 
the open air, and plain food, are called for. In all cases fresh 
air, abstinence from work if this be needed, and frequent ablution, 
should be prominent items in the treatment. 

With regard to local treatment, in the vast majority of cases 
boils always run on to suppuration, and the object to be attained 
is the removal as quickly as possible of the " core," or dead tissue, 
whilst the general blood condition must be improved. In the 
slighter forms, which will probably " subside," emollients may be 
applied — lead lotion, warm applications, poppy-head fomentations : 
or pressure may be made by means of soap-plaster, by which 
means boils are helped to abort : or aperients and diuretics 
given, if need be with tonics, to prevent their formation. In the 
more decided forms suppuration should be encouraged as well as 
the evulsion of the dead tissue, and the healing of the ulcer sub- 
sequently left. It is also necessary to allay pain. Poulticing 
must first be had recourse to : then prevention of local irritation by 
proper protection, resting the affected part if this is possible, are 
other means generally employed, as everybody knows ; but though 
practitioners know this, they do not appreciate the contingent 
fact that, inasmuch as local irritation of all kinds determines the 
occurrence of boils, local remedies, such as poulticing and the 
like, should be confined as much as possible to the exact seat of 



ANTHRAX, OR CARBUNCLE. 237 

local inflammation. Nothing is more common than the springing 
np of fresh around old boils from the neglect of this precaution. 
When suppuration has actually set in, then it is necessary to 
hasten the maturation and exit of " the core " by the application 
around its indicated locality of potassa fusa or acid nitrate of 
mercury. When the " core " has come away, any simple astrin- 
gent dressing does — ex., nitric acid lotion, with or without opium. 
The real disease in fact is over, and nature quickly repairs the 
damage done. Special general and local treatments may be re- 
quired to tone up the system and to prevent a repetition of 
mischief. 

With regard to the treatment of carbuncles, the same line of 
procedure holds good ; only the constitutional condition is one of 
more serious character. The local mischief is therefore severer 
and more extensive, the suppuration is less healthy, and a large 
extent of tissue dies. It is thought that several glands perish, 
forming so many " cores," but their surrounding cellular tissue 
is specially involved in the death or slough ; the reparative cir- 
cumscribing action is not so manifest, the healing is not so rapid 
or perfect, and serious results are more common. The general 
indications are clear — the combating of gouty tendencies, and 
the stimulation of the liver and kidneys at first, with the restriction 
of the diet to plain animal food : and large doses of quinine with 
opium — the latter if there be any decided diabetic tendency or 
much nervous prostration — the whole tempered with the aid of 
more or less stimulation, good nursing, and the freest support, as 
the case may need, are at the same time called for. 

Now all know that if the patient is tolerably strong and has no 
organic disease, the carbuncle itself will slough out, and repara- 
tive action quickly follow. Such a case gives no anxiety, but one 
may materially aid the cure and moderate inflammatory action, by 
aperients, by diuretics, by opiates, or by tonics. In some cases the 
patient's strength may fail at an early period, and here what would 
be inadmissible in another — port wine, plenty of strong beef -tea, 
and full doses of bark and ammonia — are the proper remedies. 
With regard to local measures it is also clear that the sooner the 
carbuncle is " ripe " and the dead tissue away the better ; thereby 
the sooner the pain and its effects on the body generally are 
lessened, and the sooner nature can commence repair. To this 
end one needs to keep out the blood from the tumour, and to destroy 
artificially the part that will die ; taking measures, by internal 
medicines, to bring the blood back as quickly as possible to a con- 
dition of health. And so, locally, pressure by strips of soap-plaster 
may be employed ; but if this does not seem to succeed, and there are 
serious tension and pain, the swelling must be incised. The incision 
should be subcutaneous, crucial or single, as the case may be. 

Surgeons are mostly in favour now-a-days of pressure, and 
afterwards caustic applications, with poultices to hasten the 



238 PUSTULA MALIGNA. 

softening up of the earbuncular swelling; pain being met by 
opium once or twice a day. When the process of repair is ap- 
proached, stimulating applications are needed ; the best perhaps 
is some Friar's balsam, a drachm, say, rubbed up with an ounce 
of lard, or a carbolic acid ointment. M. Soule, of Bordeaux, 
has suggested that Vienna paste be applied early, and an incision 
be made the next day : this prevents the presence of a wound that 
can absorb from without into the veins, whilst the dead tissues are 
the more readily removed ; after the incision, the wound is to be 
dressed with tincture of iodine more or less diluted. But the 
pressure plan of treatment is the better. 

In both boil and carbuncle a certain part has to die and come 
away. The sooner this occurs the better, and therefore I think 
that caustics are the best remedies, incisions being employed to 
relieve such tension as cannot be prevented by pressure. 

PUSTULA MALIGNA, OR MALIGNANT PUSTULE. 

Within the last few years very definite facts have been obtained 
in regard to malignant pustule. The disease is characterized by 
the occurrence of a boil-like inflammation, accompanied by gan- 
grenous changes, and produced by the contact of a certain animal 
poison derived from beasts affected with the disease called charbon, 
or Sang '-de-rate, which has prevailed from time immemorial on the 
Continent. 

General Description-. — The disease varies in severity according to 
the amount of tissue involved, the degree of gangrene, and the 
occurrence of secondary pysemic results. It attacks the exposed 
parts of those who come in contact with the hides or secretions of 
diseased animals ; therefore the face, and neck, and hands, are the 
chief seats of the disease. It commences as a vesication on these 
parts, accompanied by induration, an inflammatory blush of dusky 
hue, and filled with sero-sangninolent fluid. Dr. Stone, of Wal- 
pole, U.S.A., gives the accompanying representation of the early 
Fig. 19. appearance of the disease. He says, that at first 
there is a solitary serous vesicle, which has an in- 
flamed areola ; the vesicle gives place to an eschar 
bordered by a ring of vesicles as seen in figure (19), 
and seated on a hard indurated base. It seems that 
at the outset there are considerable itching, heat, 
and burning ; then the vesicle appears whilst 
the central part blackens and then forms a gangrenous eschar. 
In severe cases a large surface becomes rapidly gangrenous. 
When this stage is reached, constitutional symptoms of a typhoid 
nature develop, and these correspond in severity to the local 
changes. They follow the local symptoms, and are produced by 
absorption of poison from the gangrenous part. If death occur, it 
arises from pysemic conditions, induced from the fourth to the eighth 




PUSTULA MALIGNA. 239 

day. But the gangrene may be arrested, when the subsequent pro- 
gress of the case is that of anthrax. Malignant pustule is at 
first a local disease. Numerous bacteria have been found in the 
blood, but it is not certain what influence, if any, these possess in 
the causation of the disease, or whether they are accidental and 
secondary to the blood changes. 

The cause of malignant pustule is as stated, the contact of an 
animal virus derived from animals affected with " charbon." Dr. 
Richaud, quoted by M. Raimbert (of Chateaudun),* has observed 
the disease largely since 1S30, and he now asserts that it occurs in 
those who touch the dead carcasses of " charbon " animals, are in 
constant contact with beasts, or are stung by flies that have feasted 
on the former. The disease is very common in the plains about the 
Alps from May to October, when the sheep in their peregrinations 
die plentifully on the road, and the disease attacks those who 
reside near the line of the passage of the flocks. The disease may 
also be got by direct inoculation — as in butchers, herdsmen, drovers 
— from contact with hides or tainted hair of diseased beasts, and, 
it is said, by eating the flesh of the latter. 

In a late number of the American Journal of Medical Sciences, 
is a paper by Dr. A. H. Smith, on malignant pustule, as 
it appeared in the vicinity of Las Cruces, New Mexico , in 1865. 
During the summer of that year an epidemic resembling " charbon " 
or the malignant pustule of surgical writers, occurred. It com- 
menced as a papule of a livid or purple colour — hence the Spanish 
designation "grano negro;" and at the earliest stage the tissues 
round about could be felt to be indurated to a considerable extent 
and depth, and distinctly creaked on being incised. The section 
had the appearance of dense fibrous texture, containing in the 
meshes dark pigment. The boundary was abrupt and well-de- 
fined ; little blood flowed from it, and the sensation of the part 
was less than that of the skin around. In from seven hours to two 
days the papule became like the vaccine pustule, only livid or 
black, and erysipelatous redness extended around it, spreading 
oftentimes with great rapidity. The pustule and the swelling 
around steadily increased, as the rule. In some cases the former 
was stationary, the latter very active ; the cuticle was then raised 
by effusion and blebbed, and sloughing ensued ; the pain was 
burning, but only in exceptional cases severe. The constitutional 
symptoms seemed to bear an exact ratio to the extent of the local 
mischief ; the breath was offensive ; the tongue moist and coated ; 
the pulse quick and strong, becoming small and frequent ; and the 
skin relaxed and clammy after a while. The only one whom Dr. S. 
saw die was comatose. Great difference existed in the extent 
of the disease : in some only a small spot was present, the size of 

* De la Spontaneite des Maladies Charbonneuses chez l'Homme. 



240 PUSTULA MALIGNA. 

a split-pea, made up of a little redness, and in a day or two the 
patient was well. In favourable cases the disc of dead tissue 
in the centre sloughed, leaving a healthy granulating surface 
behind. 

Dr. Smith says: "A careful inquiry enabled me to trace it to 
infection from diseased animals." A distemper prevailed at the 
time to a slight extent amongst cattle, and was described by the 
Mexican rancheros to Dr. Smith. " The fact that in every in- 
stance the pustule occurred in a part of the body not protected by 
clothing goes far to confirm the view of the disease, that it is not 
in any degree the local manifestation of a constitutional infection, 
but always the result of direct local inoculation." He gives the 
following instance : — " Two men were engaged in skinning an 
animal which had died of the distemper. One of them had a 
pimple on the face which he had scratched with his nails until it 
bled. The other had received a scratch in the face from a thorn 
in passing through the chaparal. The day was extremely warm, 
and the men frequently wiped the perspiration from their faces 
with their hands, covered as they were with the fluid from the 
animal. In a few hours pustules were developed upon the abraded 
surfaces in both individuals. The disease proved fatal in one 
(which I did not see), and the other recovered with a considerable 
loss of tissue from the cheek." Dr. Smith says it is impossible to 
say if simply eating the diseased meat sufficed to give the disease, 
although many people declared they had not touched the meat. 
One case appeared after handling dry hides. 

In one case a woman was attacked. She had eaten with the 
rest of the family of a goat that got the distemper, but which was 
killed "for fear it should die." Several ate the flesh, but this 
woman alone was attacked, and she had prepared the goat for the 
table. 

The idea that the poison of the disease is conveyed by flies who 
inoculate it into healthy persons is supported by the observations 
of MM. Kaimbert* and Davaine.f 

It is said that bacteria are the essential cause of malignant 
pustules. The matter is involved in obscurity, but this is a question 
that I shall not enter into now. 

The Treatment consists, essentially, in fully destroying at the 
earliest possible moment the eschar or vesicating part by caustic 
(potassa fusa), subsequently incising, applying charcoal poultices, 
with chlorinated soda washes, and giving internally a cathartic ; 
followed by free doses of tincture of steel, carbonate of ammonia, 
and brandy, with generous diet. 

* Recherches Experimentales par la Transmission du Charbon par les Monch.es 
(" Comptes Rendus de l'lnstitut," 1869). 

f Etude snr la Contagion du Charbon chez les Animaux Domestiques. (Bulletin 
de l'Acad. de Med. et Gazette Hebdom., 1870.) 



DELHI BOIL. 241 

DELHI BOIL, ALEPPO EVIL, AND BISKRA BOUTOX. 

I propose to deal in this place with three diseases endemic in 
India, at Aleppo, and in Algeria, respectively, whose pathological 
position is at present uncertain, but which are believed to be allied 
in many particulars to anthrax. These three affections certainly 
all bear a close resemblance the one to the other, and it is thought 
that they are the same in nature. Compared with anthrax they 
are very chronic ; they are at first papular, then suppurate, and 
finally ulcerate. 

The Aleppo evil, Biskra bouton, and Delhi boil will be noticed 
under this head in separate sections, and I shall then make some 
special comments on the whole of them. 

DELHI BOIL. 

St/Ji. Aurungzebe, after the monarch of that name, who suffered 
from the disease ; or Bulkea, from Bulk, a place where it is said 
to arise from inoculation by a certain black gnat. 

The attention of Indian medical officers has been frequently 
directed of late to Delhi boil. The name Delhi boil is to some 
extent an unfortunate one, inasmuch as the disease is not peculiar 
to, though perhaps most prevalent at Delhi, but is known to occur 
in many localities in different parts of the East — at Garzebad on 
the Meerut or left side of the Jumna about nineteen miles from 
Delhi and adjoining villages ; at Jeypore, Scinde, Lahore, Moultan, 
Agra, Aden, Meerut, Roorkee, and Umballa. The disease first 
attracted special attention when the city of Delhi was garrisoned 
by our troops, and it was noticed that only those had it who, 
with their families and the camp-followers, did duty within the 
city walls. The so-called Lahore, and possibly the Scinde boils, 
though there is doubt on the point to be presently noted as regards 
the latter, the Moultan sores, probably the Aleppo evil, and the 
Biskra bouton (Algeria), are it would seem the same disease. 
It would not, however, be well to change these names before being 
quite convinced that these several diseases are of the same nature, 
and more light is thrown upon their pathology and cause by 
further investigation. Some such term as Oriental sore or pustule 
might then be employed to designate the disease as it occurs in 
various parts of the world. The word Delhi sore is, however, pre- 
ferable to Delhi boil. Delhi sore is not dangerous, but intractable, 
and it attacks new-comers especially. 

Typical Characters and Course of the Disease Jconwn as ^ Delhi 
Boil^ — The disease has been described as commencing by itching, 
followed by the development of a reddish spot, in the centre of which 
appears a papule or two, giving rise to the aspect of a wart, or as 
it has been described, "a small hard pimple, which, when first seen, 
has desquamating epithelial scales on its top." Dr. Fleming 
{Army Medical M&port, 1869) depicts the original appearance as 
16 



242 DELHI BOIL. 

resembling " a musquito bite, with the skin slightly elevated ; on 
examination a number of blood-vessels are seen radiating to the 
centre of this little red spot, which gradually enlarges without any 
pain, throws off its epithelium, becomes smooth and flat on the 
surface, assumes a shining appearance and a relative degree of 
transparency. The growth slowly increases in size and often 
spreads irregularly to a considerable distance from the centre by 
little ridges of smooth skin, and it would appear to attack the 
roots of the hair and sheath first whilst it is extending. The 
growth or any of its prolongations, pits on pressure and causes a 
stinging sensation, contrasting with the healthy skin around." 
Others have described the enlargement of the original spot to be 
in part produced by the development of new papules around the 
original one, these papules being seated at the hair follicles. These 
new spots coalescing with the original one and themselves, and 
producing, as above described, an inflamed, brownish-looking, 
shining induration. When matters have advanced thus far, ulcera- 
tion is imminent, and the surface may be seen to be studded over 
with deeply seated yellowish-white points, which have been re- 
garded as points of suppuration, and ova, but are in reality altered 
and inflamed hair and gland sacs. Presently a scab forms by the 
aggregation of epithelial scales and a certain amount of ichor 
discharged from the soft centre of the tumour, and then ulceration 
begins beneath the scab, especially if the " boil " is irritated. 
There is some slight variation described by observers in the early 
condition of the boil ; for example, it is said that before the scab- 
bing takes place the papule may suppurate or give place to a small 
abscess, and this one can easily understand. What is always 
found present is the ulceration going on beneath a crusted pustule. 
As before observed, the discharge and crusting rapidly augment 
with irritation. The sore itself is surrounded by a zone of redness, 
and new papules develop around it, whilst the sore enlarges by 
ulceration, is very indolent, and fails to show for a long time any 
tendency to heal. In some cases the disease is altogether of a less 
marked kind than I have now described — there is no suppuration, 
less ulceration, and scarcely a cicatrix left behind after cure. The 
ulcerated surface itself, when present, is red, flabby, and irregular, 
being studded over by fungoid granulations that bled freely. The 
surface of the ulcer discharges a thin ichor, and it is painful. Its 
edges are hard. 

Dr. Fleming {Indian Medical Gazette, Kbv. 1869) particularly 
calls attention to the fact that during the growth of the tumour 
and up to the period when ulceration begins, and when the " boil " 
is relatively transparent and shiny, the small yellowish or yellowish- 
white bodies before referred to as present, may be detected with 
a lens. If these be cut out they will be found to be altered 
hair sacs, and they will sometimes come away attached to 
scabs which are forcibly detached (See Dr. Cleghorn, Medical 



DELHI BOLL. 



243 



Fig. 20. 



History of the Bengal Native Army for 1868," by Surgeon-Major 
Ross. Also fig. 25.) 

As the ulceration advances, signs of healing usually show them- 
selves in the centre of the original seat of disease, and cicatricial 
tissue springing up gradually spreads farther and farther outwards as 
the ulceration extends, and the sore finally heals after two or more 
months, a scar remaining. The general health does not materially 
suffer. The most common seats 
of the sore are the exposed parts 
— ex., the back of the elbow, fore- 
arms, backs of the hands and 
fingers, ankles, face, legs, thighs, 
and near the scalp. The sore 
rarely attacks unexposed parts. 

I am enabled to give the two 
following sketches of the disease 
from photographs of Deputy- 
Inspector-General Dr. Murray, 
of the Indian Service, which 
were given in the Lancet a little 
while since. See figs. 20 and 21. 

Morbid Anatomy. — Some inte- 
resting observations have lately 
been made by Surgeon-Major 
Smith {Army Med. Ee/p. 1868, 
vol. x.) and Dr. Fleming (Army Med. Rep. 1869), as to the mi- 
croscopic characters of the tumours and ulcers of Delhi sore. 
The former made out the presence of " a large number of peculiar 
bodies, varying in shape from an elongated oval to that of a 
kidney or crescent-form." These were of a dark chocolate- 
brown colour as seen by transmitted, and 
of a bright orange red as viewed by re- 
flected light. Their average size was pro- 
bably equal in length to five or six blood 
discs by about two and a half to three in 
width. They had distinct cell walls and 
were filled with minute dark granules, and 
varied much in transparency. They aboun- 
ded not only in the discharges but all over 
the skin. Other cells were found in the 
discharge from open ulcers like distomata, 
full of granules in some cases, and in others 
having one end transparent, as though 
"being thinned by protrusion and conse- 
quent tension at the moment when the spot was first distinctly 
visible." On one occasion a curious animalcule was believed to 
have been discovered in the boil. The cellular bodies, as repre- 
sented by Surgeon-Major Smith, are seen in fig. 22. 




Fig. 21. 




244 



DELHI BOIL. 




These bodies are probably the ova of distomata from impure 
water, according to Prof. Aitken, but it is not unlikely that some 
may be altered epithelial growths pigmented more than usual. 
They do not appear to have been generally observed. 

Dr. Fleming has more recently done much to throw light upon 
the nature of the diseased processes in Delhi broil. When a 
section is made of the tumour before ulceration has commenced, 
the normal structures are found to be replaced by a fibro-cellular 

Fig. 22. 



49 



tissue, enclosing in its interstices a large number of cells in 
masses, the sebaceous glands and sweat glands being destroyed, 
as well as the papillary layer of the skin. The cells make up the 
chief part of the boil at this time — i.e., before ulceration has 
commenced. They are seen in the accompanying figure 23, acted 
upon by acetic acid. They are oval or roundish, yellowish brown, 
the cell wall being soon destroyed by pressure, and they contain 
two or more nuclei. The cells are regarded by Dr. Fleming as 
the essential and peculiar growth of Delhi boil. . But then there 
are very curious changes in the hairs, -pia. 24. 
They appear to be the seat of cystic 
formations. The epithelial layer is so 
/^^0M0^W-h arranged as to give rise to an appear- 
iifeSj^S^\ ance °^ a fibrous envelope, and this 
^^iw^M^'i encloses a finely granular matter (see 
fig. 24). Representations of the al- 
tered hair-balls referred to by Dr. 
Fleming are given in fig. 25. 

Pathology. — In commenting upon 
these appearances I would be under- 



Fig. 23. 



mmmm 



x 400 



The appearances seen stood as offering suggestions for the 
i n tir n t£°?h b e1r„ur 0eI \sr»Wance of future inquirers What 
is there, it may be asked, incon- 
sistent with the idea that the cell growth is but a pro- 
liferation of the connective-tissue corpuscles, an arrest x 25 
in their growth, which gives rise to the formation of a kind of 
granulation tissue, which presently degenerates to a greater or 
less extent into pus? for the cells have the appearance of pus 
cells in many cases, so far as their characters are portrayed by 
Dr. Fleming in his drawings. One can easily understand that 
such a change may be induced in the tissue of the cutis as the 
result of impaired nutrition. The so-called cystic formations in 
the hair are evidently due to immaturity of the cells that form 



ALEPPO EVIL. 



245 



Fig. 25. 



the pith, the cortical part being less abundant than usual, a con- 
dition seen in other cases where the nutrition of the body is much 
interfered with, as for instance in syphilis. 

It would appear to be a very important point to distinguish 
clearly, as a means of throwing light upon the true pathology of 
the disease, between the microscopic appearances observed before 
and after ulceration has occurred. There can be little doubt that 
after ulceration has occurred, and under the peculiar circumstances 
met with in India, ova fungi and other foreign bodies may readily 
be conveyed, by means of impure water and the like, to open sores, 
and so be found in the discharges therefrom, and it would only be 
the fact of finding these bodies or organisms in the tumours 
before they ulcerate that could be worth a moment's notice in 
proof of their being the cause of the disease. The finding ova 
and the like in the discharge of Delhi sore shows, as matters at 
present stand, nothing more than that these have probably gained 
access from without to the discharging 
surface. But Dr. Fleming's researches 
help us greatly upon the point in 
question. He gives us the characters 
of the tumour — a new granulation 
tissue — before there is any ulceration, 
and he shows that the new cell growth 
or tissue, if inoculated, will reproduce 
the disease. But if the cells were 
pus cells this might be explained by 
their possessing specific contagious 
properties, as in the case of gonor- 
rhceal or syphilitic pus. The pus, how- 
ever, from the Delhi boil will not, if 

inoculated, induce the disease; there must be with it some of the 
cell growth described by Dr. Fleming. But after all, the latter may 
be an early stage of pus, and it may be that in syphilis the in- 
oculable material is not actual pus, but granulation tissue, which 
is present in chancres and syphilitic ulcers. 

But before I proceed to enter upon the question of the causa- 
tion of the disease, it is desirable to describe briefly the general 
features of Aleppo evil and Biskra bouton. 

ALEPPO EVIL. 

The Aleppo evil, or button, is probably the same thing as the last 
described disease. It is endemic about the Tigris and Euphrates, 
at Aleppo, Bagdad, and Bussorah : it is met with at all ages, and 
attacks both natives and strangers, the latter after a short resi- 
dence. It is like the Delhi boil, confined to the cities, and occurs 
once in a lifetime. It begins as a papule, which pustulates in 
two or three months, and scabs over whilst ulceration goes on 
beneath the crust to the extent of from a quarter to two or three 




Altered hair sacs extracted 
from "Delhi Sores." 



24:6 BISKBA BOUTON, OK BISKRA BUTTON. 

inches, having like characters to those of Delhi boil. After a 
year or so the ulcers heal, leaving indelible cicatrices. At 
Aleppo the disease is ascribed to bad water. Where there is one 
tumonr it is said to be the male, if a tumour is surrounded by 
several smaller ones it is called the female. The disease is pain- 
less ; it never kills, and is indolent in its course. 

BISKRA BOUTON, OR BISKRA BUTTON, 

is called also bouton des Zibans, because of its occurrence in the 
oasis of Zab, and by the arabs simply habb. 

The following account of what appears to be the same disease 
as Delhi boil is given by Deputy-Inspector Dr. Paynter,* and it 
will be noticed that he refers to its similarity to an anthrax : — 
"We find, in the southern part of the province of Constantine, 
about 160 miles south of the sea-coast, at a military station with 
a considerable civil population of European colonists as well as 
natives, an endemic disease, so common that it is called the 
' Biskra button,' from the circumstance of its prevalence at and 
around Biskra, the first station in the desert. It is, however, not 
peculiar to this part of Algeria, for it is also found at Tougort, 
Ouargla, and Tlemcen, and is, probably, to be met with in all 
parts of the desert. It is also seen in parts of the neighbouring 
kingdom of Morocco. This singular disease attacks its victims 
during the months of September, October, and November, at the 
end of the great heats of summer. Consequently, I had not an 
opportunity of seeing it in its first stage ; but, from the description 
given of it, it appears to commence with an itching sensation, long 
before any appearance is appreciable on the skin. After a time, a 
small tubercle is perceived about the size of a very small pea, 
located, very superficially, in the layers of the skin and subcu- 
taneous tissue ; remaining stationary for some days, or even weeks, 
and causing little inconvenience ; at length it enlarges, the epi- 
dermis scales off; and, shortly, a small ulcer appears, which dis- 
charges a sero-purulent fluid. Seen by myself during the month 
of February in its chronic stage, it presents precisely what I may 
describe as a small superficial anthrax. Differing in diameter 
from one to two or three inches, these patches present the appear- 
ance I have alluded to; and when pressed, a thick purulent secre- 
tion oozes out through several openings. There were a few cases 
in the military hospital at Biskra at the period of my visit; and 
with the exception of being inconvenient, disagreeable, and un- 
sightly, did not appear to give any particular pain, or cause any 
constitutional derangement. This eruption appears most fre- 
quently on the legs, fore-arms, dorsum of feet or backs of hands ; 
on the nose, cheeks, and ears ; varying from one or two spots to 

* Army Medical Reports for 1867, at p. 438. 



BISKRA BOUTON, OR BISKRA BUTTON. 247 

a dozen, or even more. The affection lasts from four to eight 
months as a general rule ; oftentimes for a year, a year and a half, 
and occasionally for a longer period. Whatever the period may 
be, the appearance when cured, or cicatrizing of itself, as it does 
if left without treatment, is that of the cicatrix after a burn. 
The disease attacks natives, Europeans, all sexes and all ages ; 
and occasional^ 7 relapses are met with (i.e., one attack not ren- 
dering the person free from a second invasion). Of the cause of 
this affection little is known. Bad water, heat, dirt, &c, have all 
been named ; however, these are very prevalent in other regions 
where nothing like this singular disease is seen. It has been met 
with in the horse in some of those regions where the human race 
is liable to its attacks ; but not, I believe, in the dog. It is said 
not to be contagious. The cause of the affection not having been 
settled, its treatment is of course not very defined. Thorough 
change of air possibly shortens the time required for its cure, and 
is probably the best remedy. This disease partakes of most of 
the characters of the Aleppo button." Dr. Bertherand* proposes 
to call the disease Chancre du Sahara^ on account of its characters 
and its occurrence principally about the Sahara. His account of 
the disease agrees with that of Dr. Paynter, and he thinks it is due 
to the action on the body of climatic influences. 

Eow in comparing Delhi boil, Biskra bouton, and the Aleppo evil 
together, certain analogies are recognised. In the first place, they all 
attack the exposed parts — ex., the backs of the hands, the uncovered 
arms and legs, the backs of the feet, the nose, cheeks, and ears, &c. 
They all last about the same time, from several months to a year, 
or a little more. They similarly attack all ranks, ages, and classes, 
but especially new-comers, after a three or four months' residence ; 
they all leave cicatrices, and so on. The Delhi boil attacks dogs, 
but this has not been stated of the Biskra bouton nor of the 
Aleppo evil, though horses are attacked by the Biskra bouton. 
However, the inter-relationship of these diseases is a matter that 
requires investigation. Delhi boil and Biskra bouton seem to be 
especially prevalent after rains. In each disease the general 
health does not suffer greatly, if at all, and the three diseases are 
known to have oftentimes a long period of incubation. They 
break out now and then a long time even after the removal of the. 
patient from the places where the diseases are endemic. 

[It may be here stated, in reference to the observation that 
Scinde boil is probably Delhi boil, that Dr. Farquhar's experience 
leads him to conclude that the ordinary Scinde boil is very different 
from Delhi boil. There may be the Delhi boil in Scinde, he 
allows, but the Scinde boil is, according to his opinion, a true 
" f urunculus," a severe form of the boils that are so very frequent 
in the rainy season all over India. These boils are seldom met 

* Notice sur Chancre du Sahara. 



24:8 CAUSES OF DELHI SORE. 

with till after the first fall of rain, and are in many places believed 
to be connected with the eating of mangoes. This supposition is 
apparently, however, a mistake, and arises from the fact of mangoes 
getting ripe and fit for eating just after the first fall of rain. 
Br. Farquhar has seen these u rain boils " occur as frequently in 
districts of India where no mangoes were to be had as where they 
are plentiful. The boils appear to be of a malarious origin, their 
strange frequency in the legs being explicable probably by the 
dependent position rendering the circulation torpid. 

Europeans suffer more than natives from these boils, which are 
sometimes very trying to the general health from the pain they 
occasion. The inflammation will sometimes cover half the leg 
below the knee, and the induration be as large as a crownpiece. 
At other times these boils are about the size of a sixpence. Dr. 
Farquhar has counted as many as five-and-twenty on an adult's 
leg in the middle of October, all more or less in an active state, 
and he has also known a Scinde boil kill a strong man through 
continuous sloughing of the core and edges ; erysipelatous attacks 
supervening and exhausting the patient. Poultices favour the 
reproduction of these boils tenfold at times. 

It is important to gain the views of others on the question of 
the nature of Scinde boil, and as to whether Delhi sores occur as 
a distinct disease in Scinde.] 

Cause of Delhi Sore andalliedDiseases. — The disease " Delhi Sore" 
would seem to be widely existent, not only in India, but in Eastern 
cities generally, so that we must look for a common cause in 
operation over a wide area, not in anything specially peculiar to 
Delhi. * It is clearly not connected with poverty — Dr. Murray's 
reportf seems to show this conclusively ; nor does it appear to 
depend on malaria directly, since it is found to be absent from some 
of the most malarial districts. Then it has been ascribed to the 
bite of an insect, but of this there is no positive evidence. Delhi, 
it is true, is remarkable for its flies, but then Delhi sore is rare, 
whilst flies abound, amongst the suburban population. Then the 
water has been blamed for the occurrence of the disease, and in two 
chief ways ; firstly, in regard to its impurities, which it is said, 
taken internally, induce the disease, and secondly, in that the 
disease is averred to be caused by ova of insects, introduced beneath 
the skin from the water used for washing. The Biskra bouton and 
Aleppo evil are said to be caused by bad water. If the cause be in 
the water, some condition common to all cases of the three diseases, 
and the districts wherein they occur, should be found. In Dr. 

* See Report on Delhi Sores by Staff-Surgeon-Major A. Smith, forwarded to 
Government of India, July, 1869, in which he bears testimony to the fact that boils 
having all the characters of Delhi Sores are met with in a number of different places 
in India. 

f Report of Special Medical Committee Convened by Order of Government of 
India, to Inquire into Cause of Delhi boil. Dr. Murray, President. 



CAUSES OF DELHI SORE. 249 

Murray's official report, reference is made to the remarkable im- 
immity of a detachment of native cavalry drinking excellent water 
which they obtained outside the Lahore gate of Delhi. Can similar 
facts be observed elsewhere — viz., immunity of certain sections 
of the community who are using a special water supply? Dr. 
Fleming's observations on the microscopic appearances of Delhi 
boil before ulceration, in which nothing like ova were observed, 
would seem to set aside as untenable the doctrine that the disease 
is due to any parasite, and, as before observed, the fact of para- 
sites being found in ulcers is no evidence that they are the cause 
of them, and it would be surprising if they were not so found 
in India. Surgeon-Major Smith most strongly inclines to the 
opinion that the disease is caused by some parasite, and argues 
that these come from the water used for washing ; but Mr. Alcock 
{Med. Times and Gazette, Nov. 22, 1870), meets this by saying 
that the disease does not prevail amongst the water-carriers, as in 
the case of the guinea- worm disease, which it would do if it were 
an animal parasitic disease occasioned by the contact with the 
skin of certain waters containing the parasites. 

But it is important to notice some other facts. Many observers 
(Dr. Smith amongst them) agree in stating that Delhi sores are 
very liable to be immediately developed in the seats of abrasions, 
and that small sores take on in India an ulcerative character like 
Delhi boils. Dr. Smith speaks of this as occurring in the chafed sur- 
faces which occur in winter, in connexion with the wound of a dog's 
leg, &c. Mr. Cleghorn notices the same thing (" Sketch of Medical 
History of the Native Bengal Army," 1868), and so does Mr. Alcock 
{Med. Times and Gazette, loc. cit.), who has seen " an accidental abra- 
sion become a specific sore within a fortnight." Whether similar 
occurrences are observed generally in connexion with the develop- 
ment of Delhi boils is a point to notice in future. There can be 
little question that disorder of the general nutrition induced by 
climate is one element in the production of Delhi boil and its allies. 
The parts .attacked are those most exposed to injuries, and after 
all it may turn out that simple boils, wounds caused by mosquitoes, 
local abrasions and injuries, &c, because of the disordered state 
of health, take on the morbid action observed in Delhi boils. We 
are not without analogical evidence of similar disease being induced 
in like manner in this and other countries. In the West Indies 
simple sores take on not a suppurative or ulcerative action, though 
they do this sometimes, but frequently are succeeded by an hyper- 
trophous growth of the fibrous tissue as the result of climatic 
influences or racial peculiarities. 

Again, French medical officers * state that the French in China 
suffered from a species of severe ulceration (to which the term 
Cochin China ulcer was applied) ,jrtdiich was ascribed to climatic 

* Dublin Medical Press, May 28, 1862, from Surg, des Hopitaux. 



250 TREATMENT OF DELHI SOKE. 

causes. It attacked at all ages, both sexes, and men of all kinds 
of constitution. It consisted in " ulceration following some lesion 
of the skin, often the most trivial," the legs being most affected, 
the ulceration not deep as a rule, but occasionally severe and 
rapid. These and similar facts suggest the question whether after 
all Delhi sore is not a species of furunculus modified by climatic 
influences. But there are two other considerations that militate 
against the doctrine of its local, and in favour of its essentially 
constitutional nature ; the one is the immunity which is the lot of 
old residents in districts where the disease is endemic — an un- 
doubted fact ; and the development of the disease a long time after 
removal from those places in which it occurs. It may be said, if 
the disease were of parasitic origin, one might expect a certain 
period of incubation, but certainly not so long as is recorded of 
Delhi boil and Aleppo evil — viz., a year or more. We can explain 
the attack specially of new-comers to a district upon the suppo- 
sition of its being a constitutional disease, as well as upon the 
ground of its being a local affair, and it by no means follows that 
because the disease can be cured by the destruction of the new 
growth described by Dr. Fleming, that therefore the disease is local, 
since the same happens with scrofulous and syphilitic sores, &c. 

Treatment of Delhi Boil. — Dr. Fleming, who has seen much of the 
disease, states'* as the result of his observations, that we should, " as 
soon as the disease is recognised in the form of a small fiat reddish- 
brown growth in the skin, apply strong nitric acid or potassa 
fusa over the surface. One application may be sufficient if the 
growth be of short duration and does not affect the whole depth 
of the skin ; otherwise two or more applications may be necessary 
to destroy it. Strong nitric acid is recommended for this stage 
of the disease. If a Delhi ulcer shows no tendency to heal from 
the edges, and to produce healthy granulations from the bottom 
by the simplest treatment, it is then certain that the whole of the 
morbid cellular structure has not been destroyed, either by the 
natural process of ulceration or the application of local remedies. 
In this state of the disease potassa fusa should be applied freely 
(more than once, if necessary), and the ulcer treated on ordinary 
principles, as it will soon assume a healthy appearance and 
rapidly heal. Yarious other local remedies can be applied suc- 
cessfully as long as the principle of destruction of the morbid 
cellular growth is carried out." He then deals with the question 
of Prevention as follows : — " Last year a partial microscopical exa- 
mination of the ulcers which affect the nose of many dogs in 
Delhi, was made in connexion with a few experiments to ascertain 
their nature. The result of this investigation showed that they 

* Short Practical Remarks on the Nature, Diagnosis, Treatment, and Prevention 
of Delhi Ulcers, by J. Fleming, M.D., F.R.C.S., Staff -Assist. Surgeon. Delhi, 

Jan. 1872. 



TREATMENT OF DELHI SOKE. 251 

were similar to those which occur on the human subject, and also 
proved that dogs, as well as men, can easily be inoculated by the 
cellular substance from an undoubted Delhi sore. Delhi ulcers 
have been proved to be contagious, and the evidence of their con- 
tagion in numerous well-known instances giving rise to others in 
different persons, independent of those produced by inoculation, is 
quite conclusive. Delhi ulcers, therefore, as far as our present 
knowledge goes, propagate themselves in various ways amongst 
individuals or bodies of men, principally, if not entirely, by their 
discharge, which is most contagious when a thick gummy-like 
exudation appears at the upper part of a sore or from under a 
scab, just previous to the commencement of ulceration." And he 
continues — 

" The methods of prevention are as follows : — 

" I. If domestic dogs are found affected with these ulcers let 
them be cured as soon as possible. 

" II. All private native servants and those employed about the 
barracks, as well as the soldiers, should be periodically examined, 
and if the disease be detected in any stage the cases should be 
isolated and treated according to the plans recommended. 

" III. Persons exposed to the contagion would do well to wash 
their bodies and extremities thoroughly with soap and water. 
Ulcers of a similar nature to those of Delhi are common at Mool- 
tan, Lahore, and other overcrowded cities in India, as well as in 
Sind, Arabia, and Persia ; and of course the same plans of treat- 
ment and prevention which have been so successful here will bo 
equally applicable to other places. The foregoing remarks are 
based on the result of a long experience and observation in the 
treatment of this peculiar disease, as well as on many carefully- 
conducted experiments, and altogether lead us to believe that, if 
the preventive treatment be faithfully carried out, the 'Delhi 
ulcers,' after having existed many hundred years, may ultimately 
become a disease of the past." 

I have no experience in the matter to offer, but I confess 
that I think it of no little importance to attend to the state of 
the general health, to give if necessary such remedies as quinine 
or iron in full doses, and to advise, under certain circumstances, 
change of air from malarious or otherwise unhealthy localities 
where Delhi boils prevail. 



CHAPTER XIII. 

SQUAMOUS INFLAMMATION. 
GENERAL REMARKS. 

There are two important diseases of the skin with which I shall 
deal in this chapter — viz., pityriasis rubra and psoriasis. In the 
former malady, in its typical form, the surface of the body is 
deeply reddened (hypersemic), and covered by large and freely 
imbricated scales or flakes ; hence the term— -pityriasis rubra — 
applied to it. Now it has been thought that the shedding of the 
scales was the most important feature, but I am by no means 
certain that the hyperemia of the skin is not the primary phe 
nomenon and the hypertrophic growth of cuticle secondary; at 
any rate the two are equally important : and I have noticed the 
hyperemia as the first stage. In the disease there is no real in- 
flammation in the form of new products. Hebra allies it to eczema, 
and upon the ground that "we occasionally find moist excoriated 
patches on other portions of the skin, especially in the flexures of 
the joints" (see Neumann, loo. tit.). But this is infinitely rare; 
from beginning to end, there need be nothing but hyperasmia and 
scaliness present in the disease. 

There is not necessarily any change in the corium tissue or the 
connective tissue, though the hypersemia, if persistent, may be 
followed by hyperplasia and thickening of these parts, but only as 
accidental epiphenomena. On taking up Neumann's work I was 
surprised to find the following in reference to acute eczema: — 
"The eczematous places become swollen, reddened, and covered 
with vesicles, which subsequently burst and pour out a gummy 
viscid , fluid. This dries to crusts, after whose removal the sub- 
jacent skin appears moist, and then becomes dry and red, with 
white scales (pityriasis rubra)." Here the term P. rubra is loosely 
applied to the healing stage of an eczema, when in fact all its 
typical characters have vanished : whereas it really signifies a 
primary condition of things that entirely lack the phenomena in 
the deeper parts of the skin peculiar and essential to eczema. 
The pityriasis rubra I shall describe is a primary form of disease. 

In psoriasis a somewhat different state of things obtains : 
there is hypersemia of the papillary layer of the skin, with hyper- 
plasia of the epithelial elements, but I believe the latter to be the 



PITYRIASIS RUBRA. 253 

more important of the two : and in this respect psoriasis contrasts 
with pityriasis rubra — the former being essentially a disease of cell 
tissue, the latter rather an hyperemia, primarily. 

I might have classed the two diseases under hyperemia or 
hypertrophies, but in the present state of cutaneous pathology, 
have preferred to place the munder " Squamous inflammations," to 
avoid coining a new term or class. 

PITYRIASIS RUBRA. 

This is a primary form of disease characterized essentially by 
general hyperemia of the superficial parts of the skin, and 
hyperplasic growth of the cuticular layer. I may as well add 
that — I use the term desquamation for all forms of shedding of 
the cuticle secondary to other disease (see Desquamation under 
Diseases of the Epithelium). 

Clinical Features. — The disease commences oftentimes in those 
who have had a good deal of mental anxiety or who have been 
working laboriously, and the first signs are redness and scaliness 
in some part of the body — I have many times noticed this to 
be the chest — with a feeling of debility. Presently the patch 
begins to extend, and then the surface of the whole body speedily 
becomes within a fortnight or so hypersemic — of a deep red colour, 
which is lessened by pressure, and is accompanied by constant ex- 
foliation of branny lamellar scales, but wichout any exudation or 
infiltration of the skin, or any discharge at all from it. The face 
is red and "scurfy," the head also particularly "scurfy;" or in 
other words the scaliness in these parts is not quite so intense. 
The sudden development of the disease, and the way that it 
spreads so as to implicate the entire body are very characteristic. 
The developed disease varies but little in aspect during its whole 
course. Devergie remarked that P. rubra is the only disease 
of its kind which attacks the whole body from head to foot without 
leaving a sound spot. The patient sometimes does not complain 
of much inconvenience in the way of itching, but I have generally 
found that patients are tormented by " burning heats." 

The desquamation, when the disease has fully developed, may 
be very free and extensive, the whole cuticle of the hand may 
peel off en masse, as it were, and the amount of scales shed day by 
day may be prodigious. About the arms especially, the scaliness 
may be markedly imbricated in regular order, like the tiles of a 
house, the white fringing presented by the free edges of the flakes 
contrasting with the red hypersemic surface exposed beneath the 
white flaky masses. This appearance has given rise to the term ap- 
plied to the disease of dermatitis exfoliativa, whilst the hyperemia 
has suggested that of general dermatitis ; but, as I have stated, there 
is no true inflammation present in the disease. The nails, one or 
even all, may be shed. 



254 PITYRIASIS EUBEA. 

Now if the patient dies no trace of the existence of the disease 
is left behind save the scaliness, which corroborates the view that 
I take of the disease, that it consists essentially of active and in- 
tense congestion with related hyper-production of epithelial 
tissue. The disease may subside gradually by a diminution 
of the redness and scaliness, or it may become very chronic, and 
then, as a consequence of the long-continued hyperemia, the 
integuments thicken, so that the disease comes to resemble a 
chronic eczema or psoriasis, only that its history and distribution 
are so different. But as a rule the integuments, including the 
papillary layer, are not thickened : they are only reddened and scaly. 

Patients affected with the disease are generally much debili- 
tated, and after a while lose flesh, become pallid and emaciated, 
and are a very long time recovering strength again, if they ever do 
so. I have not observed the extreme marasmus and death, described 
by Hebra, result in English people. 

But there are other phenomena. The disease is occasionally, 
but very rarely, patchy, and this is due to abortive development or 
to the fact that the disease is progressing towards recovery. 

The mucous membranes in some of my cases have been usually 
greatly congested, including those of the conjunctiva, pharynx, 
and throat, and I have reason to think that pyrosis and me- 
norrhagia present in certain other cases have been dependent upon 
a hypersemic condition of the mucous surfaces of the stomach 
and uterus. 

Pityriasis Pilaris. — Devergie gave this name to a condition of 
the hair follicles found in connexion with pityriasis rubra, and a 
most perfect and well marked example of this rare sequence of pity- 
riasis rubra came under my notice in 1871. As the condition is a very 
rare one, I may be pardoned for quoting the notes of my case. 

' ' On stripping the man and looking 1 at him from behind, the whole of his back 
from poll to level of sacrum and the upper half of each arm were seen to be studded 
all over with minute very pale red elevated points or knots, the size of pin's heads, 
giving- the appearance of a much exaggerated goose-skin or a nutmeg-grater. Each 
point or knot was seated at a hair follicle, and produced by the plugging of the folli- 
cle by a collection of epithelial matter, so as to give the feel of a rasp to the hand 
on passing it over the skin. In the front these appearances were less marked, the 
papular giving the aspect of flattened acne punctata spots. Laterally the papules 
were very distinct ; over the front of the arm, from the point of the shoulder to the 
junction of the upper and middle third of the arm, the nutmeg-grater appearance 
and raspy feel of the skin were well marked, but below the arm had all the aspect 
of pityriasis rubra. From the lower part of the spine behind, to the very toes the 
limbs piesented the aspect of pityriasis rubra. In tracing up the disease from limbs 
to trunk, the aspect and condition of the pityriasis rubra gradually passed by tran- 
sitional stages into that of a nutmeg-grater : and there was no difficulty in seeing 
how the one sprang out of the other. The uniform scaly red surface was noticed 
breaking up into distinct patches by the appearance of healthy islets of skin, and 
the isolated patches came to present the aspect of red distinct papules crowded 
together. In fact, higher up it was more clearly seen that the parts of the skin 
between the follicles became less and less, and at length ceased to be, hypersemic 
and scaly, whilst the follicles remained plugged by the epithelium which had been 
shed into the follicle from the lining membrane." 



PITYRIASIS RUBRA. 255 

In fact, pityriasis pilaris is nothing more or less than plugging 
of the follicles by epithelial cells shed from the lining membrane. 
Devergie said that this condition followed psoriasis palmaris, pity- 
riasis capitis, or P. rubra ; others say general psoriasis also. I 
suspect that in such cases the so-called psoriasis palmaris and 
pityriasis capitis are themselves the remnants of an antecedent 
attack of general pityriasis rubra. In psoriasis, the follicles will 
occasionally be observed to be plugged by epithelial matter, but 
I have never seen anything like true pityriasis pilaris follow 
psoriasis. In some cases where the circulation is torpid, no doubt 
the follicles may become plugged by collected epithelial matter, 
and this condition would be a localized pityriasis pilaris. (See 
Lichen pilaris.) 

Nature of the Disease. — As I have said before, in those cases in 
which a post mortem has been made, no change has been found in 
the skin. The latter has been noted to be very pale and covered 
by fine scales. I do not therefore understand that the disease is 
more than an hyperemia of the upper layer of the cutis involving 
its longitudinal plexus of vessels, with hypertrophy of the cuticle. 
Secondary hypertrophy of the fibro-cellular textures may follow in 
the wake of the chronic stages of the disease, but I cannot regard 
this as a necessary part of the disease, and I therefore em- 
phatically deny the connexion between this disease and eczema, 
which is essentially characterized by inflammatory changes in the 
corium. But what, it may be asked, gives rise to the hyperemia 
and the hyper-production of cuticle ? I hold that it is the result 
of disturbance not merely of the sympathetic nervous system, but 
the trophic nerves, which is followed by dilatation of the arterioles 
of the skin generally, and not only of the skin, but the mucous 
membranes also, and by hyperplasia of the tissues (epithelial). 

Diagnosis. — Pityriasis rubra may be confounded with three dis- 
eases — general eczema, general psoriasis, and pemphigus foliaceus: 
and pityriasis pilaris, with lichen ruber. The differences are clear. 
Eczema is essentially a catarrhal inflammation of the skin, having 
as its distinctive features special changes in the fibro-cellular 
tissue and the rete, with accompanying of sero-purulent discharge 
drying into crusts composed of inflammatory products. It is 
never general, and never has the history of pityriasis rubra. In 
psoriasis the disorder is essentially a change in the cell life of the 
rete, with attendant stasis in the capillaries of the papillary layer, 
which is thickened primarily. Psoriasis is also not so general, 
whilst pityriasis rubra is universal, psoriasis much more gradually 
travels over the body, and does not entirely cover it. The scales 
are finer in psoriasis, not yellow and flaky ; and if removed, small 
bleeding points become visible, from the fact that the capillary 
vessels in the papillary layer are torn across. In pityriasis rubra 
the hyperemia explains all the changes; not so in psoriasis, in 
which disease the amount of cell growth is by no means in 



256 PITYRIASIS RUBRA. 

direct ratio to the degree of hyperemia, or vice versa. It is per- 
fectly true that in old standing cases of pityriasis rubra a certain 
amount of thickening from hypertrophous growth ensues, and then 
the aspect presented by the disease is that of general psoriasis ; 
but the history of the disease proves that in pityriasis rubra the 
chief features of psoriasis are wanting, and in no case do we meet 
with primary hypertrophy of the papillary layer, whilst the scales 
on being removed do not exhibit the red bleeding points spoken of 
a moment ago. Moreover, if some parts of the skin in chronic 
pityriasis rubra be thickened, those which are not so plainly 
portray the true features of the disease. Pemphigus foliaceus 
might be mistaken for pityriasis rubra, on account of the large 
flakes that are sometimes thrown off in the site of the bulla?, the 
disease consisting of bullae rapidly developed and drying up into 
lamellae. But bullae are always to be detected, whilst there is 
necessarily much moisture and a certain amount of crusting, or 
in other words inflammatory products are present. 

The lichen ruber of Hebra, or lichen planus of Wilson, ought 
by no means to be confounded with pityriasis pilaris, since in the 
former the papules are formed by inflammatory products formed 
in and outside the wall of the follicle — i.e., new tissue originating 
in the root sheath of the hair ; whereas in the latter (P. pilaris) 
the papules are simply produced by little masses of epithelium 
which are contained in or dilate or plug the follicles. In the 
lichen planus the disease is dermic ; in pityriasis pilaris it is cuticular. 
The papules of lichen ruber too are flat, red, fleshy, of shiny aspect, 
and exhibit a central puncture, which is the opening of the follicle, 
and are primary. Those of pityriasis pilaris are developed seconda- 
rily out of pityriasis rubra, and are more pale, raised, and the 
elevations they form can be picked out of the dilated follicle. 

Treatment. — Hitherto writers on skin diseases have shirked 
dealing with the treatment of pityriasis rubra. It was with me 
until lately a most unsatisfactory thing to have to treat the 
disease, for following the traditions of the past, I worked away with 
soaps, tar, and other stimulants, only, I feel sure, to prevent patients 
from getting well. But taking the view that the disease was 
essentially an hyperemia dependent upon disturbance of the 
symjmthetic nervous system, and feeling that I had to do with a 
sensitive surface deprived of its natural protecting layer of cuticle, 
I adopted a plan of soothing and protecting the hyperaBmic skin, 
whilst I gave general tonics, and to my astonishment I obtained 
really remarkable good results. In fact I have come to regard the 
disease not as incurable, but as curable. 

First — as regards general remedies. Is arsenic of use ? it may 
be asked. I have seen a few cases in which arsenic has been 
pushed to an extreme extent without in the least benefiting the 
disease ; yes, and pushed so far as to induce muco-enteritis, fol- 
lowed by emaciation and serious symptoms. Further, I had a 



PITYRIASIS RUBRA. 257 

case recently under care which came on in a man who had been 
treated by arsenic for psoriasis, and in whom the disease appeared 
during the arsenical course. I do not give arsenic in the disease 
for its cure. But it is not merely medicine that is needed. Mental 
and bodily rest may be specially required in over-worked persons. 
Then the next point, I think, is to give diuretics largely, espe- 
cially if the urine is deficient in quantity, as it sometimes is, or 
loaded with urates. The object of giving diuretics is to relieve 
the skin of work. Dyspepsia must also be properly treated if it 
be present. The next point when the kidneys act freely is to use 
tonics with a liberal hand, for the thermometer never, as far as I 
know, shows an elevation beyond the normal standard ; it does 
not indicate any inflammatory condition. I prefer quinine and 
steel, with cod-liver oil, to any other remedy, together with good 
plain food. After a while the tincture of the perchloride of iron 
in ni xv or tti,xx doses is useful, and I believe helps to constringe 
the dilated vessels. 

Locally, the surface must be protected. My plan in the early 
stage of the disease is to keep the patient wrapped up in olive oil, 
so as to prevent the access to it of heat, cold, and other agencies, 
which would only unnaturally stimulate the hypersemic skin. In 
my experience this plan is followed by good effect : the hyperemia 
lessens sometimes very rapidly, whilst the scaliness becomes less 
and less marked, and presently patches of healthy skin make 
their appearance ; the hands and feet may remain affected 
for some time, throwing off scales and flakes in abundance, and 
these must be kept covered up in oil. When the disease becomes 
chronic, or if the case is a chronic one when it first comes under 
treatment, the skin should still be soothed by being anointed with 
oil, but alkaline and bran baths are then advisable ; and finally 
recourse may be had to tarry applications, but these should be very 
cautiously used. I prefer to trust to the improvement of the 
general health to effect a cure, rather than to local astringents 
and stimulants. My last four cases of well-marked universal 
pityriasis rubra have done excellently well under the system. 

Pityriasis pilaris is to be treated by soaking the patient in alka- 
line baths to soften up the epithelial masses in the follicles, and 
by the use of a very weak ointment of unguentum hydrargyri nitratis 
(3j to ij). 

Of course there may be special symptoms demanding attention, 
such as pyrosis or menorrhagia, which should be met with appro- 
priate remedies. Some have recommended mercurials in the 
disease. I should be sorry to give them, except in alterative doses 
in very chronic cases where there is much thickening : and then I 
should conjoin their use with quinine and iron or bark. 



258 PITYRIASIS RUBRA. 



ANOMALOUS FORM OF PITYRIASIS RUBRA. 

I have observed a very curious form of disease in one case, which 
will be properly noticed here. It had all the features of pityriasis 
rubra without the hyperemia ; that is to say, there was the shed- 
ding of cuticle in flakes, but very little perceptible hyperemia 
except over the exposed derma. The patient was a man, aged 
sixty, who came under my care with purpura of the legs. When 
this got well he reappeared with the cuticle flaking off the hands 
and various parts of the body after a fashion that led me to get 
out the following history. The man stated that he had suffered 
from many attacks, "nearly a hundred times during his life." 
Some doctors have styled the disease eczema, and some psoriasis. 
The attacks last four or five days. They consisted in the develop- 
ment of a scarlet eruption all over the body, preceded by " cold 
shivers," and followed by "burning heats" and pains about the 
knees, the back, and the thighs. The redness and burning con- 
tinue till, as the man put it, the "heat burns out." Then the 
skin begins to flake off. As far as I could make out the first 
attack the man had, when he was young, lasted about three weeks, 
and had all the characters of pityriasis rubra. When the attacks 
come out the water is scanty and high-coloured. The patient is 
temperate. He suffers from debility, dyspepsia, irritable bowels, 
and water-brash at times. The hands have always suffered the 
most. At present the man is suffering from an attack, but the 
disease has been unaccompanied by actual hyperemia of late years. 
The man complains of "chills" and weakness. There is no 
redness of the skin at all, but the cuticle is flaking off the body 
in large tracts (ex., the whole forearm) in different parts. The 
surface beneath is thin and pale, and made up of newly-formed 
epidermis. The flakes of cuticle are, like pieces of thin opaque 
tissue paper, over the body. The fingers are very painful, and 
look and feel tense. The cuticle is much thickened over the hands 
and fingers (the man is a carpenter), and it looks white, opaque, and 
dry, as though it had been uplifted by fluid that had disappeared. 
The cuticle over the palm of the hand can be uplifted en masse by 
taking hold of the centre, from the parts beneath, from which it is 
•loosened, except at the borders of the palm of the hand. The 
man says the whole cuticle has oftentimes come off like a glove if 
he has slit it up over the back of the hand. It takes a fortnight 
for this " glove " to come away. In places where the fingers are 
denuded of cuticle the part is somewhat reddened. I noticed one 
curious fact, viz., on the leg and forearm the part, from whence 
the cuticle is shed when watched, became alternately reddened 
and pallid, and rapidly so. This was seen and noticed by others 
beside myself. 

I have not the least doubt that this man had originally acute 



psoriasis. 259 

pityriasis rubra, and that lie Las had recurrent attacks, in which the 
hyperaemic feature has become less and less marked, but in which 
the cuticle has still been shed. The case points clearly to the 
influence of trophic nerves in the genesis of pityriasis rubra. 1 
am by no means sure that pityriasis rubra may not recur in sub- 
jects in a more or less localized and modified form, not unlike 
psoriasis. 

Whether there be any relation between pityriasis rubra and 
psoriasis I think is fairly open to discussion. I have seen pity- 
riasis rubra supervene in a patient suffering from psoriasis, and I 
have seen psoriasis apparently arise out of a pityriasis rubra ; but 
these may be only coincidences. The question is not one ripe for 
discussion yet. 

PSORIASIS. 

General Features. — This disease — psoriasis — is characterized by 
the presence of closely-packed, heaped-up scales, of a shining 
" mother-of-pearl like " aspect, seated upon an hyperaemic cutis, 
the papillae of which are somewhat hypertrophied. The cutis, 
when the scales are removed, appearing red, and exhibiting 
minute red bleeding points that start into view when the white 
scales are removed. The white scales are composed entirely of 
epithelial cells. 

The features of the disease are the more characteristic if account 
be taken of its negative signs ; for in it there is an entire 
absence of any discharge, vesiculation, or pustulation, throughout 
the whole course of the disease. The characteristics above de- 
scribed constitute a primary condition. 

The eruption affects (by preference) certain parts of the skin 
whose epithelium is thick, especially the elbows and knees. It 
may be partial or general. At the outset the disease may be 
attended by more or less pruritus. The increase of the patches is 
by centrifugal growth, and there is oftentimes a slightly red 
margin : the scales are shed, to be again replaced by others ; in 
chronic cases the derma itself becomes very distinctly infiltrated 
and thickened. The general health is often apparently good. 
The disease is non-contagious, runs a chronic course, and is very 
prone to recurrence. 

The structure of the large scales or squamae of lepra is peculiar ; 
if the under-surface be carefully examined it will be seen to be 
pitted or marked by little hollows, and these correspond to the 
enlarged papillae of the skin ; the adhesion of scales to the surface 
beneath is decided. The scales, placed under the microscope, are 
seen to be composed of epithelial cells only, matted together, well 
formed, sometimes even enlarged ; many of the cells are flattened 
together so as to be almost fusiform, and the pressure which 
effects this results from their rapid growth and close package 
together. 

Psoriasis is the same disease as lepra vulgaris. It was at one 



260 PSORIASIS. 

time the custom to apply the term psoriasis to the ordinary 
patches of the disease, and lepra to that variety in which the 
centre of the patch clears, and the disease assumes the ring form. 
This distinction is not now kept np. 

Varieties. — Lepra begins by little minnte spots of a reddish hue, 
made up of epidermic scales heaped together, over a hypersemic 
papilla or two ; this is called psoriasis punctata. This variety 
usually affects the body and limbs. When the spots are larger 
they look like drops of mortar, and the disease is then called 
psoriasis guttata ; this variety is observed about the arms, breast, 
back, legs, and thighs. When the eruption occurs in patches 
about the size of a shilling, it is termed psoriasis nummularis, 
the coin-like variety ; it is produced sometimes by the enlargement 
of smaller spots. When the disease is in a still more developed 
condition, and consists of large patches, it is termed psoriasis 
diffusa : this often covers a large extent of surface, is always seen 
on the elbows and knees, the scales being well formed and the 
patches generally thickened, and often cracked. When the erup- 
tion takes the form of bands, it is styled psoriasis gyrata. This 
variety is always due to the running together of circles ; the scales 
are mostly thin and speedily reproduced. This variety is generally 
observed about the back. Now psoriasis may pass through all 
these phases in one and the same subject, or the features of one 
phase may be preserved in individual cases. Then there is general 
psoriasis, which may present the features of any one of the varieties 
described : also chronic, or psoriasis inveterata, in which the patches 
are much thickened and cracked, the scales large, dry, and 
adherent. The patches may be hot and tender, and slight discharge 
may occur as a secondary accident. This is what Devergie called 
" psoriasis eczemateux." It presents the characters of psoriasis, 
and, in addition, the tendency to pour out a fluid secretion, which 
dries into scales of rather larger size than those of psoriasis, the 
surface beneath being red and slightly moist. This variety is seen 
about the forearms and legs. The itching and pain are more 
marked than in psoriasis, and, in fact, the disease is a mixture of 
psoriasis and ezcema. When the scales are very white, the term 
psoriasis alphoides is sometimes used. Occasionally the accumu- 
lation of scales takes place to an unusual extent : the scales are 
heaped up so as to form crusts, something like those of rupia. 
Dr. McCall Anderson has given this the name of psoriasis 
rupioides. On removing the crust, a circular red surface is 
exposed, but it does not " discharge." There is a tendency in 
this form of psoriasis apparently to the production of pus. I have 
seen ordinary psoriasis assume the characters described as rupioid 
during convalescence from intercurrent measles, the debility con- 
sequent upon the latter favouring cell proliferation. I regard 
pisorasis rupioides as psoriasis modified by cachexia, in which 
there is a tendency to pus formation. There is no ulcerative stage, 



PSORIASIS. 261 

and therefore the word rupioides is apt to mislead ; and my friend 
Dr. R. W. Taylor, of New York, has stated his agreement with 
me on this point, after having himself made careful microscopic 
observation. Itching is occasionally troublesome in the chronic 
stages of psoriasis. The elevation of the patches varies, gene- 
rally it is about a line. 

It is customary to make certain local varieties : they are : — 

Psoriasis capitis. — The head is one of the commonest seats of 
the disease, next to the elbows and the knees : the whole scalp 
may be affected, or there may be only one or two small points of 
eruption ; when extensive, the disease travels on to the forehead, 
forming a kind of fringe along it at the upper part. There is co- 
existent disease elsewhere. The hair on the scalp thins out fre- 
quently when psoriasis attacks it. 

Psoriasis faciei. — In this local variety of psoriasis, the patches 
are often circular, they are less hypersemic, less thick, and less 
scaly than when the disease attacks other parts of the body, and 
they present consequently much similarity to tinea circinata, ex- 
cept that typical patches of the disease are seen in other parts of 
the body. 

Psoriasis palmar is and psoriasis jplantaris are important local 
varieties. These local varieties are infinitely rare. Of course, 
instances of so-called psoriasis palmaris and plantaris are common 
enough, but they are practically always syphilitic. I perfectly 
agree with Neumann as regards the rarity of genuine non- 
syphilitic psoriasis of the palm o£ the hand. Non-syphilitic psoriasis, 
however, may occur, though rarely, in connexion with general 
psoriasis. But when such a condition exists as the sole disease, 
it is syphilitic and nothing else, and the concomitance of sore 
tongue and other evidences of constitutional syphilis at once make 
the diagnosis certain. The skin in the affected parts is generally 
thick, and dry, harsh, discoloured; the scaliness is not very 
marked, but the superficial layers peel off from time to time. 
Presently the surface cracks and fissures, and healing is very 
tardy ; occasionally the surface bleeds. The muscular movements 
of the hand may be painful. 

Psoriasis unguium is mostly a complication of the inveterate form 
of psoriasis, but it may exist alone. The nails (and several are 
usually affected) lose their polish, and soon become opaque, 
thickened, irregular, and brittle; they are then fissured and dis- 
coloured in lines (from dirt), their matrix becoming scaly. 

Psoriasis also affects the scrotum and prepuce occasionally : the 
parts are swollen, red, hard, tender, scaly, fissured more or less, 
and give exit to a thin secretion, which adds to the scaliness ; 
there are pain and pruritus : and the local mischief may be the 
sole, or part only, of general disease. 

When psoriasis is in progress of cure, the scales lessen and the 
reddened elevated surface beneath comes more prominently into 



262 psoriasis. 

view, but this diminishes gradually till the eruption disappears, 
leaving oftentimes no trace of its former presence behind. It may 
leave, however, pigmentary stains, the result of the congestion. It 
is in the disappearance of patches of psoriasis that the centre 
rapidly clears, and the ringed form or psoriasis cwcmafa, or the 
lepra of old authors, is produced. 

Pathology and Cause. — Ilebra and some of the French writers 
have sought to ally psoriasis to eczema and lichen, but this juxta- 

Fig. 26. 




(After Neumann.) 

Epidermis and rete Malpighii largely developed ; papillse enlarged. 

Cell-growth along vessels and in meshes of corium. 

position is at variance with the pathology of the disease. If a 
portion of skin affected by psoriasis be examined microscopically 
it will be seen that the papillae of the skin are enlarged, the epi- 
dermic cells of the Malpighian layer being specially well de- 



PSORIASIS. 203 

veloped, especially in old - standing cases. In addition, cell- 
growths, resembling cuticular cells, are observed along the 
course of the vessels running near to and into the papillae, and 
these vessels are, like the other structures, of larger size than natural 
— they are, in fact, hypertrophied. This new cell-growth is most 
abundant in the upper layers of the corium, and about the apices 
of the papillae, where cells are piled together into little heaps, 
and no doubt are pushed forward to form the ordinary scales. 
Neumann, who has lately investigated this subject, finds that the 
vascular twigs sent by the vessels of the corium to the papillae are 
peculiarly well-developed, spread over the entire area of the 
papillae, and even disposed in circles, or twisted at the summit of 
the papillae, so that the "cells" which are outside the vascular 
walls are arranged in the long axis of the papillae at first, and 
then have a more or less horizontal direction at the apices of 
the papillae. As the vessels are so abundant, the whole stroma 
of the papillae is filled with the cells which lie outside the vessels. 
Hence there is hyperaemia of the cutis, hypertrophy of the papillae 
as a whole, and an excessive formation of the cells which or- 
dinarily go to form the epidermis, this cell proliferation com- 
mencing in the upper layer of the corium, being chiefly marked 
in the parts around the vessels of the papillae, and coming for- 
ward to the surface in the form of the white imbricated scales. 
Now these changes are primary in psoriasis; cell proliferation 
occurs to a varying extent, as the result of congestion in other 
diseases — but here it is essentially primary. The cell-growth 
may exhibit an amoebiform character. 

The preceding figure {&g. 26) is Neumann's representation of 
a portion of skin taken f fom a psoriatic patient. 

Nature of the Disease. — It was at one time the fashion — when 
humoral pathology was more in favour with physicians than it 
now is — to refer the occurrence of psoriasis to a special diathesis 
or blood state. But of the existence of such a thing as is implied 
in these two designations there is not a particle of proof in our 
possession. All we know is, that there is an overgrowth of more 
or less imperfectly formed epithelial cells in connexion with 
marked hyperaemia of the papillary layer of the skin and a certain 
amount of newly-formed tissue outside the vessel's walls ; whence 
the latter come is uncertain ! Rindfleisch expresses the views of 
German observers tolerably correctly, when he remarks that, " the 
squamous exanthem without doubt takes its origin in a chronic 
inflammation of circumscribed spots of skin. These are reddened, 
slightly swollen, and endowed with the other attributes of an 
inflammatory hyperaemia ; as the consequence of this hyperaemia, 
however, there appears not an exudation in or under the epi- 
dermis, but only a more abundant formation of otherwise normal 

epidermal cells; it is an inflammatory hyperplasia." 

For my part 1 fail to see in psoriasis more than an hypertrophy, 



264 psoeiasis. 

and cannot accept the statement that it is a true inflammation. 
I am perfectly willing to allow that it may assume an inflamma- 
tory aspect if the blood of the psoriatic patient is charged with 
bile products, uric acid, or the like ; but per se the psoriasis does 
not seem to me to be an inflammation — i.e., characterized by the 
formation of new products that tend to the formation of pus. 

But admitting that it is essentially an hypersemia with hyper- 
plasia of the epidermis, the reader will want to know what occa- 
sions these changes. Now I observe that there is no necessary 
relation, as for instance in pityriasis rubra, between the degree 
and extent of hypersemia and the amount of cell change in 
psoriasis; nor do I find physiology teaching me that such cell 
proliferation as occurs in psoriasis would be likely to follow 
hypersemia pur et simple. I am therefore constrained to believe 
that the disease consists primarily and essentially in a misbehaviour 
of the cell elements themselves — a perversion of the ordinary cell 
life of the epidermis — a true tissue disease in which the trophic 
nerves probably play the chief part. One consequence of this 
perversion would be hypersemia, and anything that increased the 
hypersemia would react upon and increase the cell proliferation. 

Causes. — Psoriasis is often hereditary. It attacks males more 
than females, and is most common between the ages of fifteen 
and thirty. Persons of sanguineous temperament are most liable 
to the disease perhaps, and it is seen in persons of all classes of 
society, and mostly in summer and winter. The cause is un- 
known. 

Prognosis. — The disease is mostly difficult of cure and has a 
tendency to recur. The most obstinate cases are those of psoriasis 
nummularis of the back and buttocks, as far as I have seen, in 
which there is much elevation and thickening and deep redness : 
and psoriasis about the hands and feet. 

Diagnosis. — lied patches covered over with white more or less 
silvery-looking scales as a primary formation, without any history 
of discharge, are the main diagnostic points. Psoriasis may be 
confounded in its local varieties with pityriasis, eczema, tinea 
circinata, erythematous lupus ; and, when general, with pemphigus 
foliaceus, pityriasis rubra, lichen planus, and the squamous syphilo- 
derm. Pityriasis is known by its thin, branny scales, which freely 
exfoliate, and do not therefore form imbricated layers, and by the 
absence of all thickening or marked hypersemia of the cutis. The 
diseased patch is not elevated, it does not feel thick and harsh, 
and the elbows and knees are not specially affected. Eczema 
always has a history of "discharge." Crusts, as distinguished 
from scales, are present in the early stage of eczema, and there- 
fore it is only in chronic eczema, when the epithelial formation is 
recovering itself, that any error can arise. In this the scales are 
mixed with blastema, they are thin and loosely attached, not 
silvery white ; there are burning and itching in eczema, and the 



psoriasis. 265 

disease is not seated at the elbows and knees. In tinea circinata there 
is a kind of scaliness, but it is rather a " fraying " of the epidermis ; 
there are itching, and a circular' form — the centre being pretty 
smooth whilst the onter edge is somewhat papular ; tinea circinata 
is unsymmetrical, often vesiculating at the edge of the patch, and 
under the microscope the scales are seen to be composed of blastema 
and epithelial cells and fat, together with spores and often myce- 
lium threads that lie among the mass ; and lastly, the disease is 
contagious and may exist in several members of a family. Ery- 
thematous lupus ought not to be confounded with psoriasis ; there 
is no true scaliness in it, but deposit in the skin, with a tendency 
to loss of substance and scarring, a gelatinous look about the 
tissue of which it consists, and a deep red colour. Lupus is 
mostly limited to the face. Pemphigus foliaceus is known from 
general psoriasis by the fact of its origin from bullae, the presence 
here and there of bullae, the absence of silvery imbricated scales, 
and the presence of large flakes or lamellae, produced by the 
collapsed walls of the bullae, together with more or less secretion. 
Pityriasis rubra has no thickening of the cutis, no papillary hyper- 
trophy, but constant exfoliation of flakes, together with small scales: 
Pityriasis rubra is also absolutely general, attacking every part of 
the body ; there is a peculiar yellow aspect about the disease which 
is well seen if the blood is pressed out of a portion of the 
affected skin, and the hyperaemia is more perfectly marked. 
Lichen planus is a papular disease. The papules are at first dis- 
crete, they are always dull red, flat at the tip, and of glazy 
aspect, and when patches form the surface may be covered with 
scales, but they are very fine and very thin, and characteristic 
papules may be seen about the edges of the patches. The con- 
fusion of Squamoas syjphiloclerm is by no means unlikely. In the 
syphilitic disease, the scales are few, fine, and adherent, they cover 
over not a bleeding corium, but a faintly red infiltrated papillary 
layer, and there are usually plenty of concomitant evidences of 
syphilis present. Eczema may complicate psoriasis, then there are 
the characters of psoriasis in addition to those of eczema. This 
is the explanation of those cases of chronic disease which com- 
mence as psoriasis, and presently exhibit more or less " discharge " 
and crusting. 

Treatment. — I now have to speak of the treatment of psoriasis 
in detail. It is only by combining in a happy manner the use of 
internal and external means, one can expect to obtain the best re- 
sults. 

My treatment of the disease is based not upon the assumption 
that the disease is caused by a special diathesis, for there is not a 
particle of evidence of its existence ; nor by the presence of a 
special blood contamination, because this would surely, as blood 
diseases always do, give evidence, by signs, of disturbance of the 
general system ; the fact being, that a patient may — if he or she 



%66 psoriasis. 

be young — be, quoad the skin, absolutely and entirely psoriatic, 
and yet in fair health, at least as regards the composition of the 
blood, which could scarcely be the case if the blood was altered so 
far as to account for the changes in the nutrition of the whole 
skin. Further, my treatment of the disease is dictated not by the 
assumption that the disease is an hyperemia, with consec- 
utive hypertrophous growth of the epidermic cells, because the 
hyperemia is not necessarily primary, as far as one can judge, 
since the amount of cell-changes bears no direct relation to the 
degree of hyperemia, and the particular cell-change is often 
absent in hyperemia ; but by the belief that the essential change 
from first to last in psoriasis is a misbehaviour of the cells them- 
selves — a perversion of the ordinary cell life of the epidermis, no 
doubt connected with some lowering of the vitality of the system, 
as all proliferations are ; and upon the further assumption that 
anything that will increase the congestion will intensify the 
disease, as is the case when gouty jn'oducts or retained excreta 
circulate through the skin ; and anything that lowers the nutri- 
tion of the body will afford the disease more play. It is to the 
negation in the first place of the whole batch of these more or less 
accidental influencing or intensifying conditions, that the operation 
of an internal remedy is first to be directed. 

General Considerations. — Bearing in mind the fact that there 
is no specific for the disease, I think the practitioner should be 
careful to note in cases of psoriasis, in reference to general treat- 
ment, the following points : — 

Whether the Disease is or is not Typical ? — typical that is as regards 
aspect on the one, and seat on the other hand. The scales in 
typical psoriasis are well formed, numerous, and white, the elbows 
and knees being markedly affected by the disease ; whilst if the scales 
be few, fine, and adherent, and the disease, though extensive, 
does not attack the elbows and knees; if there be much more 
staining of the skin than usual, and the patches are small, circular, 
and generally distributed, the observer should be on the alert to 
discover a syphilitic taint in the system. Untypical psoriasis as 
regards naked-eye features may be accounted for by the occurrence 
of psoriasis in syphilizecl subjects. It is the discovery of con- 
comitant evidences of taint . in the system that affords the true 
guide to treatment. And there is another feature, which is still 
more' suspicious — that is, a multiformity of aspect : if there be 
any tendency to ulceration here, to the formation of tubercles or 
knots there, especially about the palms of the hands or soles of 
the feet, or the formation of dark crusts, as one sees occasionally, 
about the legs, then the presumption of a syphilitic taint becomes 
strong. Donovan's solution is a good remedy for untypical cases 
of the kind referred to. 

Whether the Disease is Acute and General, or Localized and Indo- 
lent f — In the former case, the skin is sensitive to external irritants, 



psoriasis. 267 

and liable to be easily congested from external irritants, and it is 
a very excellent plan to give diuretics freely for a while, so as to 
relieve the skin, as it were, when the disease shows a tendency to 
invade a large portion of the surface rapidly. This is a particu- 
larly satisfactory line of treatment when the disease assumes an 
inflammatory aspect, or is accompanied by pyrexial symptoms 
of any kind or in any degree. Where the disease is localized and 
indolent stimulating remedies may be used freely and at once. 

The Age of the Patient. — Attention to this point is of very great 
moment. In the young, one has to deal with mal-nutrition and 
want of food, or a strong hereditary predisposition ; in the middle- 
aged, with mal-assimilation, syphilitic taints, &c. ; and in the old, 
with gouty and rheumatic habits of body, in association with the 
circulation of uric acid and other excreta in the blood, and with 
complicating organic disease of internal organs functionally re- 
lated to the skin. If I may draw a practical conclusion from the 
results of practice, I should certainly say, that most frequently 
the young suffering from psoriasis will require to be fed up : 
and the old to be treated with a view to the remedying of defi- 
cient excretion. The young are free from syphilis, gout, dys- 
pepsia, functional and organic diseases of internal organs, which 
impurify the blood and often aggravate psoriasis : in fact, I am in 
the habit of saying to students that cases of psoriasis may be divided 
into two classes — psoriasis in the young, to be cured by cod-liver 
oil and iron and quinine as regard general remedies : and psoriasis 
in the old, to be treated by tonics it is true, but also by anti- 
dyspeptical remedies, diuretics, alkalies, mercurials, as the case 
may be, since a variety of special concomitant conditions, not pre- 
sent in the child, influence the psoriasis greatly. 

Station of Life. — There is a wide difference to be made between 
the hospital and the well-to-do private patient. In the former, 
man or woman or child, there is frequently exposure of the surface 
to alterations of temperature : there are often poor living, deficiency 
of fresh vegetables or meat in the diet of the child or adult, and 
milk in that of the young. There is in operation in women, 
again, the lowering effect of over-lactation, without proper means 
being available for the due sustentation of the mother, under 
ordinary conditions. The hospital patient, too, suffers under a 
lack of proper ablutionary arrangements, which gives the skin 
less chance of remaining in a healthy state. In the better class 
of society, high living and the free use of wines, stimulating dishes, 
and the like, without the taking of proper exercise, are at work to 
impurify the blood, and it may be give it an irritating quality, as 
regards a skin disposed to be psoriatic. Hence the value of 
aperient tonics in these instances. 

Diathesis of Patient. — I invariably treat psoriasis in lymphatic 
and strumous people by the free exhibition of cod-liver oil in con- 
junction with other remedies : this is a course I never omit, and I 



268 



PSOEIASIS. 



think it serves me well. I have mentioned the syphilitic taint. 
If, as sometimes happens, the psoriasis takes on an eczematous 
appearance, I regard this as an indication that the nervous system 
is specially deficient in tone, and I have recourse to nervine tonics 
accordingly. 

When should we give Arsenic f — »I think in cases where the scali- 
ness is well marked, and the disease in other respects typical, that 
is, attacking the elbows and knees as well as other parts ; where 
there is nervous debility ; after having counteracted gouty in- 
fluence, and got the excreting organs into due working order, if 
necessary ; and when the disease is chronic. 

Dr. E. Lipp advises* the subcutaneous injection of arsenic for 
the cure of general psoriasis and extensive chronic eczema. He 
uses a watery solution, containing a tenth of a grain for a dose, 
which is injected at intervals of from one to two days. The dose 
may be gradually increased. The best seats for the injection, Dr. 
Lipp says, are the lower part of the back ; slight irritation only 
follows, and disappears in a few days. This observer records some 
six instances in which good results occurred, but it seems that 
after 8S grains were used in one case in forty-eight days, and 4*5 
grains in another in thirty-eight days, new spots of eruption appeared, 
though the old eruption went — a telling argument against the sub- 
cutaneous use of arsenic. The consequences of the injection were 
in some cases as follows : — 

The pulse was rendered more frequent. The temperature was 
raised, in one case rising to 101-85 degrees Fahrenheit. The 
appetite was lessened, thirst increased, diuresis was excited, to- 
gether with a feeling of constriction of the thorax, nervousness, 
headache, dizziness, nervous cough, tickling in the larynx, and 
injection of the conjunctivas. But all these disturbances, except 
the increased frequency of the pulse, ceased upon lessening the 
quantity of the injection or suspending it altogether for from one 
to three days. 

For my own part I prefer, in giving arsenic, to give it in the 
solid form as follows : — arsenious acid, 1 grain ; quinine, 20 
grains; extract of henbane, 20 grains; extract of gentian, 20 grains; 
to make twenty pills, one to be taken after breakfast and dinner. 
In some cases I combine reduced iron with the pills. Of course 
they must be made with care, and the ingredients thoroughly 
incorporated together. 

As regards local measures I have already said that in acute and 
general psoriasis, the skin is very readily stimulated and congested, 
and, when this is done, the disease is likely to spread ; so I have 
found over and over again. Hence I conclude — and the treatment 
adopted on this supposition shows how true the conclusion is — that 
in the early stages of every case of psoriasis, especially in the 

* Archiv far Derm, und Syph., 1869, iii. p. 362. 



psoeiasis. 269 

young, where congestion is marked, and especially where the 
disease shows a tendency to spread and to develop itself in new 
places, the skin shonld not be stimulated, but simply soothed — 
the object being to diminish, prevent, and dispel congestion, 
through the agency of which the disease is enabled to spread and 
develop — whilst exhibiting appropriate internal remedies. In 
the later stages, and in certain cases from the beginning, stimu- 
lating the skin is not followed by any but good results ; but here 
congestion, if present, is not of the active, but rather the passive 
kind, but stimulating remedies should be employed where no new 
patches are developing, and where scaliness, rather than redness, 
predominates. These considerations constitute rules for the use of 
local applications in psoriasis : palliatives alone I hold should be 
used in the early and congestive stages ; and stimulants, resolvents, 
revulsives in the indolent and chronic stages, where the cell 
changes are the most noticeable feature. From doing violence to 
these therapeutical dicta, an immense amount of mischief is in- 
flicted. I am positive that I have — following the routine plan of 
treatment in years gone by — spread the disease (in the young 
especially) by the careless use of tar ointment ; of this I have no 
doubt whatever. There is another point of great moment in the 
local treatment of psoriasis : to be sure that our remedies, applied 
for the cure of the disease, reach its real seat. It is by no means 
unnecessary to urge the importance of getting away the layers of 
scales in cases of psoriasis before applying our tarry preparations 
and the like. This is done by a judicious combination of alkaline 
baths and water-dressing, or, where the disease is extensive, wet 
packing. But there is this to be said in reference to all watery 
or liquid applications, whether it be for the softening up of patches 
or the removal of scales by maceration, that some oily or unctuous 
matter should invariably be applied after their use, so that evapo- 
ration may be hindered as much as possible, and so the patch or 
patches be prevented from becoming harsh, dry, and cracked. In 
fact, I think the maceration, or water-dressings, should never be 
resorted to, without the after application of unguents or oils of 
some kind or other. 

I will now proceed, having indicated the general principles upon 
vjhich treatment is to be conducted, to sketch certain variations of 
treatment, both local and general, that seem adapted for particular 
classes of cases. 

I will refer to the case of the child first. If the disease is pretty 
general over the body and the skin is irritable, the patient should 
be soaked in an alkaline bath, containing two ounces of bicarbonate 
of soda, with two or three pounds of clarified size, every night for 
a quarter* of an hour or twenty minutes, and subsequently be" freely 
anointed with oil. Not only does the bath and oil soften up the 
integuments, remove the scales, and soothe the skin, but I am by 
no means sure that the oil does not get in part absorbed, and 



270 PSOKIASIS. 

nourish. This plan should be pursued for some time, so long in 
fact as there is any disposition exhibited to the development of 
fresh spots. Afterwards to the baths at night may be added some 
sulpburet of potassium, a quarter or half an ounce at first. The 
use of the alkaline baths may be, if preferred, followed up by the 
application of some mild mercurial ointment (see Formulae, No. 
138), or some tarry preparation (see Formulae, No. 108). If this 
plan stimulates, it had better be given up. I have lately tried, at 
Dr. Auspitz's suggestion, mercurial inunction, in the case of a 
young girl, who had seemed to improve up to a certain limit, but 
had come to a standstill, even getting worse under various treat- 
ments — but with the effect of curing the patient completely. It 
is a plan I shall pursue with a view of testing its real merits. My 
general treatment for psoriasis in the young is now, in fact, the 
use of cod-liver oil and steel and quinine, alkaline and bran baths, 
with a free inunction of oil into the skin. I cannot say much in 
favour of arsenic. 

As regards cases of ordinary psoriasis in the adult of an acute 
character, and in which the disease is characterized by a certain 
amount of congestion, I likewise have found alkaline and bran 
baths, with inunction of oil in the first instance, prepare the way 
for a more effective plan of remediation. But so long as fresh 
spots are appearing, as a rule I withhold tarry preparations ; and 
if there be any pyrexia, or the skin be irritable and congested, I 
use the simple diuretics freely. In fact, when the disease is 
actively increasing, the emollient, diuretic, and aperient treatments 
should be first used. 

If the disease is slight and localized to a few spots only, one may 
at once begin with tarry applications, for the scales are thereby 
removed sufficiently well. An ointment composed of olive oil 3 j, 
pyroligneous oil of juniper 3 ij, and acleps § j, may be used night 
and morning. At the hospital I employ creasote, gtt. vj, nitric 
oxide of mercury gr. vj, adeps § j. A bismuth ointment is likewise 
efficacious. Of course attention is to be specially directed to the 
mode of life, mal-assimilation, nervous debility, &c. But sup- 
posing that the body is chronically affected, and that the scali- 
ness is the most marked feature, and the patches of disease are 
not particularly thickened, the patient being in tolerable health, 
I then have recourse to water dressing and wet packing, which 
are of no little value at times. One thing must not be forgotten — 
viz., that it is simply out of the question to get an Englishman to 
waste very much time over medications. There is his disease, 
consisting of irregular patches of psoriasis, say all along the out- 
side of his forearm or about his legs, his thigh, and his body, and 
covered thickly with scales. The doctor wants to soften up the 
patches, but the patient won't be packed, or stay in a water-bath 
for several hours. In these cases one or two places may be 
selected and wet rags applied, with oiled silk outside, in the 



PSOKIASIS. 271 

evening before the patient goes to bed, as he sits and does his 
writing or his smoking. An arm and a leg, or two arms, may be 
taken one night, and a second leg and arm the next night. By 
the time the patient goes to bed, the patches have undergone 
sufficient maceration; the scales can be all removed, and some 
greasy application can be used. The following is a very good one 
to an ordinary case of psoriasis which is passing on to the chronic 
stage : — Nitrate of mercury ointment, 3 j to 3 ij : powdered oxide 
of zinc, 3 ij ; solution of lead (liquor plumbi), 3 ss ; carbolic acid, 
fl. drops, ij ; olive oil, 3 j ; or 3 iss. The carbolic acid can be gradu- 
ally increased, or the pyroligneous oil of juniper substituted for it. 
When the patches are not much thickened the maceration of the 
cuticle may not be required, and an ointment composed of a few 
grains of white precipitate and nitric oxide of mercury to the 
ounce of lead may be applied night and morning with excellent 
effect (see Formula, No. 97). Water-dressing or packing is some- 
times too stimulating, in which case it must be used less fre- 
quently, whilst oil inunction should be more freely practised. As 
the disease is, or becomes, more chronic, strong tarry preparations 
may be used, the object of these being to check the cell prolifera- 
tion without over-stimulating the skin. There are three kinds of 
tarry fluids in favour — the oleum fagi (fagus), the ol. cadini 
(juniper), and ol. Rusci (betula alba). These may be used in the 
proportion of one part to three or four of oil or lard, and are 
equally efficacious. 

A favourite formula is that given in the Formulary at "No. 83. 
It is applied with flannel or a coarse piece of cloth, and is firmly 
rubbed into the part night and morning according to the effect. 
It is good for psoriasis of the scalp, but I find it too irritating for 
general use. 

When the disease becomes still more chronic and indolent, and 
where the patches are much thickened, or where certain old spots 
continue to exist in particular parts without change, it is then that 
the so-called soap treatment and the use of absorbents and re- 
vulsives are called for, and are found to be very efficacious. The 
soap treatment consists in rubbing soft soap, from two to six 
ounces, according to the extent of the disease and the sensitive- 
ness of the patient, into the diseased patches very firmly with a 
piece of rag night and morning, until the epidermis is rubbed off, 
and the congested derma bleeds, when the part is dressed with 
litharge ointment; successive rubbings being adopted towards 
different regions day by day, the patient being kept in a blanket 
all the while. The soap inunction, in fact, is pursued until each 
patch of disease is softened up and the derma excoriated. 

The orthodox Vienna mode is to place the patient between two 
blankets, or to make him wear a woollen shirt and drawers after 
the friction with soap, which is rubbed in twice a day for the first 



272 psoitiAsis. 

six days ; once a day on the seventh, eighth, and ninth days, a 
bath being given on the thirteenth or fourteenth day, because if 
given earlier the skin is apt to become excessively tense and 
uncomfortable. To me this seems an odd way of treating an 
English private patient, and he would be a lucky man who should 
continue to keep up the confidence of the patient under it. 

Now I believe that the plans of macerating in wet packing, and 
the soap treatment, do well in a certain number of inveterate and 
indolent cases, in Englishmen ; but that they can be used with us 
so extensively, or to such an extent, as in Hebra's cases, I am 
prepared to deny, not only as regards psoriasis, but other diseases. 
I prefer in the very chronic psoriasis of the adult, water dressing, 
baths of sulphuret of potassium, and weak mercurial ointments, as 
far as local measures are concerned. But of course, in connexion 
with the use of these local measures, the practitioner will give 
such internal medicines as will fulfil the general indications before 
alluded to as desirable to secure in the treatment of psoriasis. 
The skin of an Englishman is more apt, it seems, to take on 
inflammatory action — that is my experience, judging of the 
results obtained from the adoption of foreign therapeutical recom- 
mendations; and it requires soothing remedies in much greater 
abundance. Indeed, whilst the same general principles of thera- 
peutics of course hold good in regard to cutaneous troubles 
amongst English and the continental nations, I most emphatically 
say that there are important differences which must be observed as 
applicable to the two, and I enter my protest against the prevalent 
opinion and belief, that exactly what will suit a German or a 
Frenchman will suit an Englishman. 

Differences in the pathological conditions of the same disease, 
as seen in Vienna and London, are observed, and such being the 
case, merely even d priori, one may expect that some differences 
of treatment may be required to suit the respective constitutional 
conditions which result from the operation upon individuals of 
different modes of life, climatic influences, particular diet, habits, 
and a dozen other like things. 

It is too much the fashion to accept German statements and 
opinions — most encouraging as they are — as perfectly representing 
English cutaneous medicine. I repeat, then, that in Englishmen, 
psoriasis demands a much more soothing treatment, and a much 
more careful use of irritant and stimulant remedies, than is gene- 
rally supposed. 

In the very chronic cases of disease, where one finds the general 
health good, the persistent use of arsenic in the solid form is the 
best treatment, and phosphorus seems oftentimes to act effectively 
in connexion with tonics or arsenic in those whose nervous 
system gives evidence of two much wear and tear, from profes- 
sional or other work, or mental care and anxiety. In other 



psoriasis. 273 

cases, when any evidence of a rheumatic tendency can be detected, 
as, for example, in the occurrence of sciatica, I at once proceed 
to the employment of alkalies in large and persistent doses. 

Some of the most difficult cases the practitioner is called upon 
to treat, are those occurring in the aged, though, of course, they 
are not numerous. The disease often has a history of twenty or 
twenty-five years' duration, it assumes an inflammatory aspect, 
tends to become complicated with eczema, may be associated with 
various organic diseases ; or it occurs perhaps in those who have 
lived freely — port-wine drinkers it may be — and who have a 
gouty tendency. It is often the case, that the disease is made 
worse by all the ordinary external applications. These are most 
difficult cases to cure, partly because of the obstinacy of the 
patients in declining to pursue any one plan of treatment, tired 
as they are of trying different doctors and remedies. I believe 
that packing in oil is best for these cases, with the free use of 
liquor potassse and quinine internally, for these patients some- 
times bear arsenic very ill. When the skin is freed from scales 
and becomes less irritable, I know nothiug so good as a weak 
nitrate of mercury embrocation, used after wet packing to certain 
portions of the body about eveiy other day; the embrocation 
being cautiously used. But I prefer the oil-packing to any other 
remedy, and it can be used each night, the patient being packed 
for the night. In cases in which a tendency to eczema shows itself, 
where the psoriatic patches are of circular form, thinnish, pale, 
scattered generally over the body, irritable, and accompanied by 
much discoloration of the skin, such waters as those of Harrogate 
are very good, in conjunction with sulphur baths. Now and then 
very special debilitating influences are at work to depress the 
patient, such as mental anxiety, hyperlactation, or intense anaemia. 
These necessarily require treatment by appropriate remedies ; rest, 
good diet, iron, and the like. 

My main object in dealing with treatment has been first to 
point out that there are very important conditions of the general 
health to be attended to in patients suffering from psoriasis ; that 
these materially influence the disease ; that the action of these 
conditions is quite clear ; and that our treatment, directed against 
these influencing conditions, is not an empirical, but a most 
reasonable one, though the actual cause of the psoriasis itself may 
not be known. Secondly, to point out the necessity, whenever 
congestion is at all a distinct, and particularly when it is a decided 
feature of psoriasis, of at once ascertaining, if possible, whether 
there be any special condition of the general health or of blood to 
account for it, and if so to prescribe appropriate remedies, such as 
diuretics, antidyspeptics, and the like ; and of adopting, in regard 
to local medication, a soothing treatment by emollient applica- 
tions, alkaline baths, wet packing, and subsequent oily inunctions 
18 



274 psoeiasis. 

and the like, before using those particular remedies which tend to 
check the cell proliferation, which is the essence of the disease. 

The regulation of the diet of psoriatic patients is an important 
part of the treatment. In acute and general cases, all stimulating 
fluids and seasoned articles of diet, with sugar and such things 
as pastry, veal, &c, are to be avoided. In the majority of cases 
plenty of meat is required. 

Special formulae for psoriasis other than those already indicated 
will be found in the formulary at No. 39, 85, 108, 109, 137 138, 
172, 180, et seq. 



CHAPTEE XIY. 

DIATHETIC DISEASES. 

Under the head of diathetic diseases I include the strumous, the 
syphilitic and the leprous diseases of the skin. Objections have 
been taken to the formation of such a class, on the ground that 
after all, so far as the dermatologist is concerned, these diseases 
are characterized by the development of new formations (granu- 
lation tissue) in the skin, and they ought to be classed under the 
head of neoplasmata or new formations with cancer and lupus. 
But I am entirely of a different opinion. It is not merely to the 
formation of new products in these diseases, as in the case of 
cancer and lupus, and the removal of these products by local mea- 
sures, that the practitioner has to direct his attention, but also to 
the general nutritive tendencies of the individual that he must 
have regard, and to the important antecedent disturbed states of 
the system that prepare the way for the formation of the new 
products. In lupus and cancer the local disease is in reality the 
disease. 

In struma, syphilis, and leprosy the changes in the skin are but 
a small part of the whole disease, and only evidence of a disposi- 
tion on the part of the tissues of the body as a whole, to become 
changed and disordered. In classing, therefore, leprosy, syphilis, 
and struma together, I do it with the express object of directing 
the reader's attention to to the general condition which produces the 
local skin changes. The word " diathesis " has been, and is now- 
a-days even, used in a most vague sense. It signifies " a morbid 
disposition" of the body as a whole, to exhibit particular kinds 
of local morbid changes, characteristic of particular diatheses. 
In diatheses as I understand them, and as exemplified in syphilis 
and leprosy, the whole nutrition is impaired primarily by some 
specific influence. In the case of struma this impairment is 
mostly an hereditary transmission. Diatheses have each certain 
physiognomical peculiarities, as shown in the conformation and 
general nutritive tendencies of the strumous subject, and the 
cachexia of the syphilitic or the leprous individual. 

Diatheses are evidenced by a tendency for local morbific changes 
of the same kind to spring up Avidely in many parts of the body, 
and by the tendency of changes of the same nature to develop 
again and again in the same subject. There is a complete unity 



276 SCROFULODERMA. 

of character preserved in regard to local diseases occurring in 
connexion with diatheses. There is another feature of diatheses 
that is very significant. These dispositions to particular kinds of 
morbid change, may be impressed upon other non-diathetic 
diseases occurring in diathetic individuals, and this alone seems 
to show that these dispositions are general and uniform in the in- 
dividual in regard of any particular diathesis. The reader must 
have noticed already that I have constantly pointed out this fact 
of the modifying influence of diathesis upon skin diseases. The 
strumous habit of body especially, often modifies the more common 
diseases of the skin. For instance, in psoriasis the crusting is 
more distinct, and there is a tendency to the intermingling of pus 
corpuscles with the epithelial scales. So in ordinary eczema, in 
strumous subjects, there is more than ordinary infiltration of the 
skin, more pus production ; the cellular tissue beneath, and the 
sebaceous glands are implicated ; and the swelling and excoria- 
tion are much greater. This modification is due to the stru- 
mous diathesis. 

The above reasons induce me to make a separate section of 
diathetic diseases, from which, however, I exclude lupus. 

SCROFULODERMA. 

This disease does not require to be dealt with very elaborately. 
It is " scrofula of the skin," and only a part of the general 
diathetic condition, which is evidenced by the ordinary signs 
of struma in greater or less degree of expression. As regards 
the skin, scrofula is generally characterized by the appearance at 
the outset of indolent, dull red, soft, tubercular formations, that 
rapidly suppurate, and are soon covered over with darkish scabs, 
from beneath which oozes an unhealthy pus. Ulceration to a 
greater or less degree takes place, with the formation of exuberant 
granulations at times, and the healing is accompanied by distinct 
scarring. The whole disease is of the most chronic character. One 
can scarcely mistake the strumous ulceration for any other 
disease ; it may spread and cover a large extent of surface, and in 
this case the ulcerated surface is half covered by darkish irregu- 
lar crusts, whilst the ulceus discharge a thin disagreeable dark 
pus, and granulations are flabby and pallid, bleeding freely on 
being touched: the edges of the ulcers are livid, and various 
attempts at repair are made. The mucous surfaces of the 
nose or eye may be inflamed and slightly ulcerated and onychia 
may be present. There are old scars of former strumous disease, 
and the whole aspect of the patient is a sufficient tell-tale of the 
disease. 

The treatment is generally successful, and consists in the adoption 
of better diet, the use of cod-liver oil, iodide of iron, the phos- 
phates of lime and iron — certainly not arsenic — and locally an 



HEREDITARY SYPHILIS. 277 

astringent ointment of tannin, or acetate of lead: or mercurial 
plaster: or iodide of lead ointment to the indolent ulcerated 
surfaces. Residence at the seaside is also desirable. 

SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 

It would be out of place if I were to attempt to discuss the 
question of the origin of syphilis or the nature and course of the 
primary (or chancrous) disease from which spring the various 
eruptive manifestations of the action of the syphilitic poison upon 
the skin. I am only concerned in this place with the secondary 
and tertiary phenomena of syphilis, viz., those changes that occur 
in the skin and fibrous textures as the consequence of the intro- 
duction of the syphilitic poison into the system, and the influence 
it exercises in modifying the nutrition of these parts. 

It is, from the moment that the syphilitic virus operates gene- 
rally upon the system that the dermatologist, as a rule, becomes 
interested in the subject of syphilis. The operation of the virus 
gives rise, in the first instance, to fever — a true syphilitic fever, and 
coincident with the development of this fever the skin begins to be 
affected. But the dermatologist has to deal also with hereditary 
syphilis, and must be well acquainted with the features of erup- 
tions in the hereditarily syphilized. In this case the phenomena of 
initial syphilis will be absent, whilst those which declare the 
syphilis to have already modified the general constitution at large, 
and to have led to special local evidences of this fact, will be pre- 
sent in greater or less abundance. Syphilitic eruptions may be 
divided into two groups, as they occur in connexion with acquired 
or hereditary s} T philis. 

But there is another group of cases which should not be lost 
sight of in dealing with syphilitic eruptions. These are cases in 
which the eruptive phenomena are not essentially syphilitic, not 
primarily produced by syphilis, but in which they arise as inde- 
pendent essences, in persons who have become syphilized, and 
which undergo modification by the syphilitic taint as a consequence. 
These are ordinary eruptions modified by the syphilitic taint. 

HEREDITARY SYPHILIS. 

Before I proceed to speak of syphilitic eruptions as ordinarily 
seen, I will deal with hereditary syphilis, and syphilitic eruptions 
the consequence of hereditary syphilis. 

Hereditary syphilis is practically synonymous with congenital or 
infantile syphilis. The child, however, may be tainted, not through 
parental influence, but through the medium of the milk of a syphi- 
litic nurse. Hereditary syphilis may be derived (a) from the 
mother contaminated before or after conception ; (b) from the 
father (the mother being healthy) ; and (c) when the parents are 
both syphilized, and, as a consequence, generally in an intensified 



278 HEREDITARY SYPHILIS. 

degree. This form of syphilis is uncommon before the end of the 
second or beginning of the third week, and it is rare after the 
sixth month ; the usual period of its occurrence is when the child 
is about three weeks or a month old. No one can mistake the 
tainted infant. The general aspect is more or less marasmic. The 
child presents a shrivelled " old man "-like aspect. The skin is 
dirty, muddy, it has lost its elasticity, and hangs in loose folds ; it 
is dry, often exfoliating, and, more or less erythematous about the 
buttocks. The cry of the child is harsh and cracked (characte- 
ristic), and "the snuffles, produced by inflammation and ulcera- 
tion of nasal mucous membrane, are present." The disease is fur- 
ther characterized by the presence of mucous tubercles about the 
anus and the mouth ; fissures at the angles of the mouth ; ulcera- 
tions of mucous surfaces ; by a high arched palate ; by the 
inflammation of the thymus gland ; various eruptions over the 
body, especially about the feet and hands in the form of erythemata 
or bullae ; a subacute onychia is possibly present ; and these, 
together with a family history of syphilis, are diagnostic. 

With regard, however, to the eruption, it is generally in the 
form of a dull red erythema of the hands, feet, and peri-anal 
region, with or without tubercular formations ; but it may in 
cachectic subjects consist in ugly ulcerations arising out of 
tubercles, bulke, or pustules. 

The diagnosis of the disease is easily made by the general maras- 
mic aspect of the infant, the palmar and plantar affection, espe- 
cially if these be bullous, and the mucous tubercles occurring about 
the mouth and anus. 

But it is not only in the very young that hereditary syphilis 
shows itself,' but in those of older age. I believe, as the result 
of clinical observation, that morbid changes in the skin of ano- 
malous forms, the consequences of inherited syphilis, are not 
uncommon, only that they are confounded with strumous inflam- 
mations. I have seen papular, bullous, pustular eruptions, ulcera- 
tive and gummatous disease clearly traceable to inherited syphilis 
in children of four, five, ten, and even in young persons of seven- 
teen or twenty years of age. Of course the lapse of time, in great 
degree, neutralizes the action of the syphilitic tendency, but in those 
cases in which mal-hygiene, mal-assimilation, insufficient diet, and 
the like have reduced the individual, the specific taint often as 
it were vents itself in disease of the skin. 

It will be observed, in regard to these cases, that whilst there 
are evidences of the actual inheritance of syphilis, they are not so 
marked, either locally or generally, as in those who show them just 
after birth ; and whilst it is to some extent by a process of positive 
diagnosis that the nature of the complaint is determined, yet the 
diagnosis is, in great measure, strengthened by negative evidence 
and the inability to bring the disease to answer to the description 
of other and non-syphilitic diseases. 



ERUPTIONS FROM ACQUIRED SYPHILIS. 279 

The individuals of whom I am speaking will come to the physi- 
cian with an eruption presenting peculiar and unusual features, 
invariably, however, running an indolent and chronic course, and 
unattended by itching. The eruption will, perhaps, be multiform, 
for instance, papules and pustules and squamous patches occur 
together, but there is a general tendency to ulceration in the indi- 
vidual places. Now, this ulceration is not explained by the exis- 
tence of a scrofulous habit of body, or by other common causes of 
ulceration, and yet there is a state of general debility, or even a 
cachectic appearance about the individual. He or she is generally 
pallid, the expression is anxious, there is a thin pinched look about 
the face, and especially the root of the nose, the countenance is 
waxy or earthy looking, and the skin may be of the same aspect. 
Then, very frequently the remains of interstitial keratitis are dis- 
covered, together with " pegged " teeth and scars of old ulcera- 
tions about the mouth or anus, whilst the mother or nurse may 
possibly give such information as will lead the practitioner to 
conclude that the child was syphilized at the time of its birth. I 
have on some occasions traced the existence of syphilitic symptoms 
in these cases in the mother before or just after the birth of the 
child. I have seen and treated mother and child, the latter 
being five, six, or seven years old, together for syphilis, in these 
unusual cases that simulate struma, with immediate benefit. 

The actual eruption seen in these cases of inherited syphilitic 
disease in grown-up children may be papular, in which case it may 
be general ; or it may be bullous giving place to ulceration, or pus- 
tular giving place to ulceration ; or it may be essentially rupial and 
ulcerative from beginning to end. The diagnosis is made first by 
way of exclusion — other than syphilitic causes being put aside as 
not explaining the disease, and then by defining the existence of a 
cachectic condition, the nature of which is indicated by the remnants 
of old mischief of a syphilitic nature about the mucous surfaces, the 
teeth and the eyes, &c, and by the nature of the eruption itself. 

The Treatment. — It should be essentially a tonic one. Good 
living, fresh air, rest, avoidance of fatigue, fattening up with cod- 
liver oil, the removal of anaemia by iron, are essential items in it, 
whilst the special taint is met by small alterative doses of mer- 
curials, and by the exhibition of iodide of potassium. 

I regard these late developments of inherited syphilis as very 
important from a clinical point of view. They are not by any 
means recognized items in the list of cutaneous diseases. 

EKUPTIOXS FEOM ACQULRED SYPHILIS. 

The first result of the incoming of syphilitic poison into the 
system, in the ordinary course of events, is the occurrence of 
syphilitic fever. This febrile disturbance occurs from the sixth to 
the ninth week after the development of the primary disease. Its 



280 ERUPTIONS FEOM ACQUIRED SYPHILIS. 

onset is often not marked. It is delayed in regard to time of 
occurrence in the case of patients who have been mercurialized, 
and in fact the pyrexia may be practically unnoticed under such 
circumstances, or the whole disease may be less severe and less 
general. When it does occur, there is a rise in temperature to 
100° or even 102° F., but it is not so great as in the acute specific 
diseases. The fever lasts two, three, or four days at the outside, 
and is accompanied by a roseolous rash. " The blood is charged 
with a poisonous principle, and all the organs and structures 
supplied with that blood suffer to a greater or less extent. The 
brain evinces its suffering by mental dejection ; the nerves by a 
general feeling of prostration and debility .... there is often 
neuralgia (nocturnal) .... the pulse is quickened .... the 
tongue coated, white, broad, and indented by the teeth. The 
fauces are more or less congested, the tonsils and soft palate being 
frequently swollen ; there is irritation of the larynx, producing a 
mucous cough and often nausea .... the conjunctiva is con- 
gested and muddy, and the whole skin is remarkable for its yellowish 
and dirty appearance, looking as if saturated with impure and 
discoloured humours." (Wilson.) The patient with syphilitic 
fever, I may add, is pale, taciturn, depressed. The rheumatic 
pains are seated in the large joints, the back of the neck, and 
chest ; they are severe at night, and, as Kicord first noticed, may 
be specially sub-sternal. They are attended also at times by 
marked headache, which is paroxysmal. The patient may suffer 
from night sweats, palpitation of the heart, and sleeplessness. 
The syphilitic fever always leaves a patient in a more or less debi- 
litated state. They feel they have had a temporary illness, for 
which they are certainly the worse, and this may be exhibited by 
lowness of spirits, loss of flesh, tone, appetite, and the like. Of 
course, as I have before said, this state of things may be little 
if at all marked, in mercurialized subjects. After the fever, erup- 
tions of various kinds follow, and are accompanied by changes in 
the mucous membranes, by deposit of syphilitic tissue in the 
fibrous structures, in the bones and the internal organs. 

Syphilodermata generally exhibit the same elementary lesions 
as ordinary eruptions ; they are erythematous, papulous, and 
squamous more especially, but also bullous, tuberculous, vesi- 
cular, pustular, &c. They, however, possess certain special 
characters which are generally mentioned in text-books, and be- 
fore proceeding to give the features of the several forms of eruption 
in detail I will enumerate these features. They are as follows : — 

1. There is a history of syphilitic inoculation, which tells its tale 
by the syphilitic fever (due to the circulation of the poison) a 
moment ago noticed ; and, in addition, by the presence of cica- 
trices, indurations, scars, and stains about the penis and groin, 
in the seat of chancres and buboes. 

2. Syphilitic eruptions are symmetrical. 



ERUPTIONS FROM ACQUIRED SYPHILIS. 281 

3. Their colour is peculiar. It is described as copper-coloured ; 
in reality "a reddish yellow-brown." (Wilson.) It is dull red at 
first, and becomes coppery after a while, and as the eruptions 
vanish, a dull red or yellowish dirty stain remains for a varying 
length of time. In the early stages of the disease the tint may be 
violet, but this soon becomes replaced by the coppery hue. It is 
well marked in the tubercular forms, and at the circumference of 
ulcers and pustules. 

4. Their form is peculiarly circular. This feature is not perhaps 
of much moment per se, but in conjunction with other points it 
affords some aid in diagnosis. It may be destroyed or prevented 
by the confluence of other patches, but even then the typical 
form can be recognized in the component parts of the patch of 
disease. During the progress of syphilitic eruptions there is a 
tendency on their part to an interchange of characters the one 
with the other, a papule becoming a pustule, a pustule a rupial 
sore, and so on. 

5. The scales in syphilitic eruptions have some peculiarities. 
Syphilitic scaly eruptions are composed usually of small circular 
spots. Scales or squamae are thin, oftentimes very fine, gray, and 
few in number ; fewer and lighter than in non-syphilitic cases. 

6. The crusts and ulcers are peculiar. Crusts are thick, greenish 
or black, and firmly adherent. Vesicles are flattish and do not 
readily rupture. Ulceration is a common feature ; the ulcerated 
surface is ashy gray, covered with a pultaceous substance, and 
bounded by sharply cut edges. Cicatrices are whitish and reticu- 
lated, or dull and brownish, leaving in their place on disappearance 
a yellowish stain. Fissuring is marked in the squamous forms. 
The horse-shoe form of pustulation or ulcer is very characteristic. 
A serpiginous mode of increase in eruptions is suspicious. 

7. Syphilitic eruptions are, moreover, as the rule, unattended 
either by pain or itching. With the exception of mucous tu- 
bercles and some forms (moist) of infantile syphilis, syphiloder- 
mata are said to be generally unaccompanied by heat or pruritus 
during their existence. I must say there are exceptions to the 
rule. In syphilitic lichen, and even erythema (roseola), the pruri- 
tus may be marked. In the tubercular forms, just prior to ulcera- 
tion, the process of softening renders the tubercles sometimes 
painful and tender. 

8. Polymorphism is a feature of syphilitic eruptions. This is 
very characteristic of syphilitic disease. Several different kinds 
of eruptions often co-exist, and this is a rule of general applica- 
bility. It is no unusual thing to see papules, pustules, and tu- 
bercles co-existent in the same syphilitic subject, and, as before 
remarked, one form of eruption may gradually assume the charac- 
ters of another. 

I now proceed to give the salient features of the various syphi- 
litic eruptions in detail, according to the common arrangement, 



282 EXAXTHEMATOUS SYPHILIDE. 

but the reader will find some good remarks upon these eruptions 
and their nature and mode of production, from my own point of 
view, later on. 

Now the eruptions consecutive to the primary disease are divided 
into secondary and tertiary. There is no distinct line of demarca- 
tion between them; the division is an arbitrary one, secondary 
eruptions being those which are more superficial and of earlier 
occurrence, tertiary those that occur later on in the disease, and 
consist in affections of the deeper parts — e. g., the bones, fibro- 
cellular tissue, and are accompanied very frequently by ulceration, 
and a markedly cachectic state of health. 

Syphilitic eruptions begin to show themselves at the same time 
that the syphilitic fever occurs — viz., from six weeks to two months 
after primary inoculation with the syphilitic poison. The first and 
earliest form of syphilis of the skin is the 

EXANTHEMATOUS SYPHILIDE, OR SYPHILITIC ROSEOLA. 

This is one of the earliest secondary symptoms of constitutional 
syphilis. It occurs generally between the sixth and ninth week 
after the reception of the primary mischief. It is preceded by 
pyrexia of mild character, prostration and very frequently more or 
less irritation of the mucous surfaces — e. g., redness of the fauces, 
sore throat, &c. The syphilitic fever is of greater or less degree. 
The attack very commonly follows a debauch or over- heating of the 
body, or fatigue, or some extra bodily exertion. The eruption 
commences as little round spots of a pale-red colour, varying in 
size from that of a split-pea to that of a sixpence or a shilling and 
more, with very well-defined edges. These may appear very sud- 
denly, often in the course of a single night, acquiring in a little 
while a perfectly pale-rose tint. The spots are unattended by 
itching, and observed usually, most perfectly and abundantly, on 
those parts which are well covered and kept warm by clothing, 
especially flannel ; hence particularly on the trunk. The little 
patches may be slightly elevated, isolated, and round ; they fade, 
but do not disappear on pressure. They do not itch. Sometimes 
they are scattered pretty freely over the trunk, the upper part 
of the chest (especially the lateral parts), and over the back. 
They may be visible about the face. When the rash fades, an 
occurrence that takes place in three or four days, or not for some 
little time, it always leaves behind a branny-like or more deeply- 
coloured stain ; the epidermis desquamates in largish but thin 
scales. This latter condition becomes more decided, after a few 
days. What strikes one is this: that there is evidently a large 
amount of scattered eruption without apparent cause, without 
local irritation, and only the slightest febrile disturbance, the 
eruption leaving behind a dirty staining. The coppery hue is 
evolved out of a roseola, which may be somewhat dusky on its 



SYPHILITIC STAINS. 283 

first appearance. In ordinary roseola the tint is vivid, and quickly 
disappears, the stains left by syphilitic roseola, when the con- 
gestion has disappeared, constitute the so-called Jfaculce Syphiliticce, 
about to be noticed. In syphilitic roseola there is usually not 
only redness of the fauces and tonsils, but slight ulceration. 
Enlargement of the glands of the cervical and inguinal regions 
follows, and alopecia occurs coincidently in many cases. The 
diagnosis must be made between this and ordinary roseola, in 
which concomitant symptoms of general infection are absent: 
and roseola from copaiba, which is attended by most decided 
itching, and attacks the wrists and hands and arms mainly. I have 
known patients with syphilitic roseola declared to be suffering 
from impending variola when complicated by roseola variolosa, 
measles, and typhus. But in the first instance the temperature 
will be mueh too high, the patient will look too ill, and the head- 
ache and feeling of illness be much too great for syphilis, whilst the 
roseolous eruption will be purpuric rather than anything else. 
The gravity of the symptoms in the acute specific diseases has 
been too marked for syphilis, and all doubt has been cleared up in 
a few hours by the course of the disease. 

I have said that syphilitic roseola leaves behind certain pig- 
mentary stains. These stains are common after all forms of 
syphilitic eruption, but I cannot find a more convenient place to 
notice them than this. 

SYPHILITIC STAINS, OR MACULE SYPHILITICA. 

These stains may be, as before observed, a remnant of any form 
of syphilis, but mostly of roseola. The little roseolous spots, 
which soon fade, assume a dirty brown aspect, and subsequently 
become of a rather lighter hue. These maculae are neither 
elevated nor itchy, they are circular; in size they range between 
that of a f ourpenny-piece and that of a florin ; they are scattered 
over a large area, and are usually isolated, but occasionally con- 
fluent, forming sometimes bands ; they do not disappear on pres- 
sure. Their especial seats are the neck, the breast, the face, especially 
the forehead, and the arms. In children the maculation occurs in 
a more general form and is so complete that the whole surface has 
an earthy look. In acquired syphilis, in adults, there is oftentimes 
a significant staining, particularly well seen about the forehead, but 
also over the whole body, as the result of cachexia, but nowhere is 
it better marked than in the face, which looks as if sunburnt. 
Maculae syphiliticse are unattended by desquamation. It has been 
said that they constitute a primary form • of disease, but it is the 
rule that they commence as roseolous spots, though the red blush 
may be very ephemeral and escape detection. They can only be 
confounded with pityriasis, but in the latter there is desquamation, 
itching, elevation, and absence of the copperish hue, and a want 



284 PAPULAR SYPHILODERM. 

of circular form. Chloasma is attended with itching ; the colour 
is fawn, without any shade of copper tint ; the surface is elevated, 
rough, and desquamative, and the microscope detects parasitic 
elements ; chloasma too is peculiar in its seat. Syphilis never 
produces such staining as exists in chloasma or leprosy. In the 
latter it is oftentimes marked over large tracts of the skin. 

PAPULAR STPHILODERM. 

Different authors make very different divisions of the phases of 
papular syphilis. Generally two varieties are described, the 
acute and the chronic. It appears to me that this is a very un- 
necessary and useless division. I make two varieties of papular 
syphilis : the first in which the disease begins by follicular hy- 
peremia, this being followed by a deposit about the follicles and 
the formation thereby of papules. The second in which solid little 
growths of syphilitic granulation tissue are found in the skin, and 
these papules may be lenticular in form and shape or fiat and 
largish — i.e., papulo-tubercular. 

The former, answering to the acute form of the syphilitic lichen 
of authors, occurs generally some five or six months after inocula- 
tion with the syphilitic poison. 

It consists in the development of small red points that soon 
become papules, which are packed closely together. The papules 
are seated upon the face especially, but also the trunk (on both 
aspects), the neck, and less frequently the limbs; they become 
covered over with fine grayish scales, and occasionally become 
pustular or ulcerate. The eruption is scarcely successive, for it 
arrives at its full extent within a couple of days or so : but it may 
sometimes be made up by several outbursts of the disease. Slight 
febrile disturbance precedes the development of the rash. When 
the acute stage is passed, the disease appears to be constituted by 
little dark points or papules seated upon a somewhat dull-red base ; 
in a few more days this dark hue is replaced by a well-marked 
copper colour, and more or less desquamation. The papules are 
collected in little groups which are very significant of the disease. 
The disease lasts a month or so, leaves behind more or less 
staining, and little cicatrices or pits, which are very characteristic. 
This form of syphiloderma, then, commences with congestion of 
the follicles and subsequent deposition which takes the form of 
papular elevations ; the peculiar coppery tint is masked at the 
outset by the congestive redness, and only shows out markedly 
when the latter disappears. 

The chronic form of lichen possesses a slower and more indo- 
lent course, simply. The papules are primary solid formations, and 
not follicular. They are large, numerous, flat and broad, copper- 
coloured, without distinct areolae, local itching, pain, or heat; 
they are seated on the outer sides of the limbs, the forehead, the 



VESICULAR SYPHLLODERM. 285 

trunk, and even the scalp. The papules are successive in mode of 
appearance, and on their subsidence leave behind copper stains. 
The papules often become pustular. 

The Diagnosis of papular syphilis is generally easily made. A 
prior history of syphilitic inoculation ; the general distribution of 
the eruption, its coppery hue, and its tendency to become tuber- 
cular ; the absence of pruritus and pain ; the general cachexia 
of the patient, and the evidence of concomitants — e.g., mucous 
tubercles, roseola, nodes, sore throat, &c, suffice. 

VESICULAR SYPHILODERM. 

The sjrphilitic eruption, in which vesicles form the leading 
feature, is rare. It takes the form of herpes in the vast majority 
of cases, but it may be varioliform or impetiginous. 

Syphilitic Herpes. — In the first place the patient has all the 
general symptoms of syphilitic inoculation with coincident sore 
throat : and the vesicular form of the syphilitic eruption shows 
itself at a tolerably early date, about six months or so after the 
receipt of primary mischief. As far as I have observed the disease, 
it consists of patches of herpes of the ordinary character, save that 
they are altogether more indolent, and lack heat and itching ; their 
edge is well-defined and copper-coloured. The vesicles may abort 
and oftentimes quickly dry up. The patches, moreover, increase 
by centrifugal development. The crusts which form are largish 
and adherent, and each patch may last a good time, longer than in 
ordinary herpes. In all cases a copper-coloured stain is left behind. 
This form of syphilis of the skin is found on the face, limbs, trunk, 
and penis, and often in association with other forms of herpes. The 
herpetiforni syphilide may occur in the form of a ring with a clear 
centre. I have seen it in the seat of zoster as a syphilitic herpes zoster. 
In this case the indolent painless course and the long duration of the 
disease, the copper-coloured base, the concomitance of syphilitic 
general symptoms, left no doubt about the nature of the disease. 
Two cases of this kind I can call to mind. In one case the 
herpetic eruption started about the buttock, and ran down towards 
the thigh at its back part. Syphilitic herpes of the penis is by no 
means uncommon. M. Doyon, of Lyons, has published a little 
brochure on recurrent herpes prseputialis of syphilitic origin. He 
remarks very truly that " Recurrent herpes is often mistaken for 
chancroid. It is the fourth in order of frequency amongst venereal 
affections, gonorrhoea occupying the first place, then chancroid, 
and then syphilis. It uniformly follows some primary venereal 
affection, dies away, and then reappears for many years together 
about every two months. The group of vesicles appear in close 
proximity to the site of the primary affection. Each eruption 
lasts about five or six days, is unaccompanied by any febrile symp- 
toms, and disappears by desquamation. It is more frequently a 



283 VESICULAR SYPHILODERM. 

sequela of chancroid than of gonorrhoea, and of this than of true 
chancre. Its first appearance is usually about three weeks after 
the termination of the primary lesion. Each group of vesicles 
has a diameter of somewhat less than an inch, and the successive 
crops reappear very constantly in the same place, the seat of 
election being apparently the corona glandis or prseputio-balanal 
fold. Its outbreak is often induced by excess in drinking, a few 
w r akeful nights, want of cleanliness, and, above all, by sexual 
intercourse. It may persist longer than five or six days, and he 
records a case where the small ulcers left by the vesicles lasted 
eighteen months. As regards the diagnosis, herpes prseputialis is 
not likely to be confounded with any other affection than a soft 
chancre, and from this it is distinguished by the itching and pain 
which accompany its outbreak, the number and mode of grouping 
of the vesicles, the presence of an inflammatory areola round each, 
the non-contagious character of the disease, and, finally, the non- 
occurrence of bubo. M. Doyon appears to consider that the 
origin of the affection may be traced to a primary or to an 
inherited dartroics diathesis, or that state of constitution in which 
eczema, lichen, pityriasis, and other similar cutaneous affections 
are likely to develop." The herpes is immediately due to the 
irritation of the- nerve trunks in a syphilized subject. Syphilitic 
herpes is known by its persistency, the indolence of its course, 
the small ulcerations left, and the concomitants. 

Varioliform Syjphiloderm. — In this variety the vesicles are about 
the size of lentil-seeds, disseminated and intermingled with little 
bullae, which are pointed, and now and then umbilicated. They 
possess the characteristic areola, crust over in a short time, 
beneath which a copper stain and perhaps ulceration exists. 

Syphilitic Eczema. — Some writers make a syphilitic eczema. I 
do not believe in the existence of such a disease. Eczema may 
occur in a syphilitic subject, but I have never seen a syphilitic 
eczema. I have, however, seen about the face a condition which 
might have been designated syphilitic impetigo. That is to say^ 
quasi-rupial sores may run together en masse, the result being the 
production of a thick greenish-yellow layer of dried secretion, like 
the crust of a marked impetigo, which covers over an ulcerating 
surface beneath. But in this case, though the face is caked over 
like crusta lactea, the origin is not from vesico-pustules as an 
impetigo, but rather as a rupia. There is a raised copper-coloured 
edge, and ulceration, going on beneath the crust, which may 
destroy deeply and widely. I have had two cases of this kind in 
which the nose was half destroyed, and which yielded readily to 
anti-syphilitic treatment energetically practised. One patient was 
sent to me for severe impetigo faciei : the whole nose and cheeks 
being more or less covered by free, yellowish, thick crusts like an 
impetigo scabida, but there was clearly something more than 



BULLOUS SYPHILODEKM. 



287 



ordinary impetigo present, as shown especially by the presence of 
marked ulceration, and a general history and aspect of syphilis. 



BULLOUS SYPHILODERM. 



Under this head are ranked rupia and pemphigus. 

Bupia (see fig. 27) is known by the development of small flattish 
bullae (surrounded by a faintish areola, perhaps by none at all), 
few in number, containing at the very outset transparent serosity, 



Fig. 27. 




The face shows in the smaller and less marked spots B. simplex; in the 
two projecting masses about the forehead B. prominens. 

but very speedily a mixture of blood and pus, giving place by 
desiccation to thick scabs, beneath which is more or less unhealthy 
ulceration, yielding a nasty, dirty, foetid discharge. The crusts are 
diagnostic ; they are dark, stratified in such a way as to be conical, 
like an oyster-shell. According to my experience small ecthy- 
matous pustules may be the starting-point of rupia. 

The rupial spots may be seated on any part of the body, the 



288 PUSTULAR SYPHILODEEM. 

face, head, limbs, or trunk. The mode of the production of rapial 
crusts is readily understood. Beneath the crust first formed 
ulceration goes on, the ulcerating surface giving out a discharge 
that dries and augments the crusts from below. And as the area 
of the ulcer increases the successive layers of dried secretion will 
be more and more extensive, so that the rupial crusts finally comes 
to be made up of successive layers of dried discharge, of gradually 
augmenting size from above downwards — hence the conical form 
of the crust. It is only in syphilis that ulceration is found 
gradually extending in all directions, and secreting after the manner 
stated : so rupia is always syphilitic. Now varieties of rupia have 
been made according to the size and shape of the crusts and the 
degree of ulceration : — if the spots are of fair size the disease is 
termed rupia simplex (fig. 28) ; if the crusts are large and pro- 
minent, rupia prominens ; if the ulceration is marked and the 
patient cachectic, rupia eschar otica. But these are merely fanciful 
elaborations, and the student need make only one rupia. 

Syphilitic Pemphigus. — This form of syphilis of the skin was at 
one time denied an existence, but it does occasionally occur. It 
is seen in children who are congenitally syphilitic : and as part 
of the manifestation of syphilis in those who exhibit the signs of 
constitutional tainting — i.e., earthy hue of skin, snuffles, wasting, 
mucous tubercles, lepra, &c. In such children the pemphigus is 
observed about the hands and feet especially, the bullae being 
abundant, their contents puriform, and they possess a tendency to 
ulcerate more or less deeply, the ulcers having a copper-coloured 
areola, and a nasty, dirty, foul surface, with thinly cut edges. 
When the disease is congenital, it is seen most frequently before 
the end of the first fortnight of existence. Sometimes the bullse 
are not well marked, but scabbing is marked, the disease exhi- 
biting a close relation to rupia ; indeed herein is seen the link as 
it were between rupia and pemphigus. The ulcerative tendency 
displayed by syphilitic pemphigus is no doubt dependent upon the 
cachectic state of nutrition brought about by the syphilitic poison, 
and it is exhibited specially by those who are most cachectic. Of 
course, non-syphilitic pemphigus may occur in the young, but in 
this case the concomitants of constitutional infection are absent. 

Syphilitic pemphigus undoubtedly occurs as a rare thing in the 
adult in connexion with other evidences of syphilis. 

PUSTULAR SYPHILODERM. 

In my opinion there are three primary and one secondary 
forms of syphilitic pustules. The primary forms are syphilitic 
acne, syphilitic ecthyma, and syphilitic inflammation of the upper 
part of the follicles. The secondary form is the papular or tuber- 
cular syphilis which pustulates. I need only say of the latter that 
the pustules are found about the forehead and face, and on the 
trunk; the pustules are successive, numerous, isolated and scat- 



PUSTULAR SYPHILODERM. 289 

tered ; soon acquire a coppery hue, and are indolent. Sometimes 
they are flattened, at other times conical, the points or summits 
being purulent ; thick greenish crusts may form, and beneath them 
is ulceration depressed in its centre, and leaving behind a more or 
less marked cicatrix and copper-coloured stain ; this secondary 
pustulation is often associated with other forms of syphiloderma 
and preceded by febrile disturbance. It is remarkably indolent 
sometimes. 

I now have to speak of the primary forms of pustular syphilis. 
Of course in all these cases the general condition of the patient 
and the concomitants, sore throat, nocturnal pains, &c, show that 
the patient in whom they occur is syphilized. 

Syphilitic inflammation of the follicles explains itself. The dis- 
ease attacks the portion of the follicle above the opening of the 
sebaceous glands, and it is seen about the scalp and also the side of 
the face, most frequently. It occurs pretty early in the course of 
syphilis, and the spots are marked by a hardish base, a distinct 
areola presently copper-coloured, an indolent course, and the 
occurrence of cicatrices,. with dull stains. 

Syphilitic acne is common. In it the entire sebaceous glands 
are usually involved. This acne occurs as the sole form of eruption, 
and it is then seen about the face, especially the sides of the face, 
on the scalp, and also the trunk. Unlike simple acne, it leaves 
the cheeks oftentimes free, and is not limited to the face and 
back. It also occurs in a scattered form in connexion with other 
forms of syphilitic eruption — ex., papular syphilis. The acne spots 
are the size of lentils or small split-peas ; they are often varioloid 
in appearance. They have a hard base, an indolent course, dark 
adherent scabs oftentimes, and they leave distinct cicatricial pits 
behind and dark-coloured stains ; but the hard bases and subse- 
quent cicatrices are very characteristic. 

Syphilitic ecthyma is seen about the trunk, but especially the 
limbs, the lower more than the upper, and occasionally the head. 
The pustules are phlyzacious, scattered, with a coppery base, and 
are indolent. They are scabbed over with dirty brown or blackish 
scabs, covering ulcers with indurated and dark edges, which on 
healing leave behind cicatrices and characteristic stains. The 
disease may commence as a quasi- vesicular (bullous) disease, 'each 
vesicle having a red base, quickly enlarging, pustulating, and 
breaking out into obstinate ulcers ; the crusts are peculiarly thick, 
and 'very adherent. I have seen syphilitic ecthyma run on into 
rupia of a fairly marked kind. 

The relation of ecthyma, pemphigus, and rupia, of syphilitic 
origin, is very close indeed. 

The Diagnosis. — When papular or tubercular syphilis pustulates 
and assumes the aspect of ecthyma, no difficulty can arise in diag- 
nosis. Syphilitic ecthyma is distinguished from simple ecthyma by 
the special history of the case, the concomitance of other syphilitic 



290 SQUAMOUS STPHILODEEM. 

lesions, the coppery line, the thick black crusts, the foul ulcers, the 
depressed scar, and the absence of a livid areola ; syphilitic from 
simple acne, by the ulceration at the apices of the pustules, and the 
cicatrices left after the healing of the pustules, by the absence of 
pain, the indolent, 11011-imiammatory aspect of the pustules, and 
by the antecedent and concomitant histories. 

SQUAMOUS SYPHILODERM. 

I cannot, in accordance with general custom, describe the scaly 
syphiloderm as a syphilitic psoriasis. In this form of disease little 
growths of syphilitic tissue appear, not in an elevated form as in 
tubercular syphilis, but as it were in a more diffused manner, 
forming little circular patches which have a scaly aspect, because 
the growth beneath disturbs the normal formation and disposition 
of the epidermis, and so gives rise to scaliness, in the first instance, 
but exfoliation of syphilitic infiltration subsequently. Since the 
patch is formed, not by hyper-production and heaping up together 
of epithelial cells, but by new tissue, I do not think it right to 
employ the term syphilitic psoriasis, for no psoriasis exists. 

This squamous syphiloderm — inasmuch as people are not gene- 
rally syphilizecl till puberty — does not commence as the rule till after 
that time. It assumes the aspect of psoriasis guttata / that is to say, 
there is a disposition to a circular form, and the eruption is made up 
of solitary isolated spots, the size of a pea, a shilling, or less, covered 
by squamae, which, unlike those of ordinary psoriasis, are not large 
and silvery, but hard, adherent, and grey, and seated upon a copper- 
tinted basis, which is smooth and shining, not elevated, not papular, 
not red, as in non-syphilitic psoriasis; a white rim surrounds 
each patch, and this is formed by the loosening of the cuticle 
around the circumference. These spots are scattered over the 
arms, breast, face, and trunk generally, but the elbows and knees 
are free from them, and when the palms of the hands or soles of 
the feet are diseased, the skin is dirty, harsh, scaly, cracked, and 
fissured. These palmar and plantar diseases will be noticed spe- 
cially by-and-by. Hardy has described a syphilide cornee ; it is 
merely plantar or palmar psoriasis, in which the epidermis hardens 
very much, and the coppery areola is well marked. The squamous 
syphiloderm is often intermingled with the papular and tubercular 
varieties of eruption. 

Diagnosis. — There are seven leading features which, taken 
together, are positively diagnostic of the squamous syphiloderm. 
(1) If limited to the palms of the hand and soles of the feet, it is 
in the majority of cases syphilitic. (2) The disease does not attack 
the elbows and knees by predilection, as in the simple forms. 
(3) It is generally displayed in little circular patches, which are 
isolated and not confluent. (4) The patches have a peculiar 
whitish line circumscribing them, due to the elevation and attach- 



TUBERCULAR SYPHILODERM. 291 

ment of the cuticle. (5) The squamae are thin, small, grey, and 
repose upon a coppery base. (6) There are generally significant 
co-existences of specific infection. (7) Copper- coloured maculae 
follow in the wake of the disease. 

In non-syphilitic psoriasis, the scales are numerous and loosely 
packed together over an hypersemic corium, which bleeds if the 
scales are removed ; whereas, in syphilis, the scales are few, and 
lie on a palish red infiltrated corium. (See also Palmar Syj)7iilo- 
derm, to he noticed presently^) 

TUBERCULAR, SYPHILODERM. 

This is a decidedly common form of secondary syphilis. Its 
tubercles for practical purposes may be regarded as an exaggerated 
condition of papules. They vary a good deal in size (from that of 
a pea to that of a nut), but they are always indolent, and may 
occur about the face, especially the nose, forehead, and side of 
the head, but also any part of the body. They sometimes are 
so closely aggregated together in various localities as to give rise 
to thickened patches. The papules possess a coppery tint, and 
are fiat and hard ; they are formed by syphilitic granulation tissue. 
When they ulcerate, which they do when large, they become 
covered over by thick and black adherent crusts. Now different 
appearances are produced according as the number of tubercles 
is large or small, and according as they occur over a limited or a 
wide area. But in all these cases the essential nature of the 
tubercle — a solid, firm, fleshy elevation — can be recognised : where 
patches form, of course at the extending edge of disease. 

The simplest form of tubercular syphilis consists in a few 
tubercles localized to some particular region — for example, the face, 
or the nape of the neck, or the shoulder ; and I may be pardoned 
for calling attention to one diagnostic feature of a negative kind 
which the tubercles present, that they cannot be made out to be 
enlargements of the follicles (acne, or follicular hyperaemia) of 
the skin, they present no central punctum — they are indeed 
neoplasms. In the tubercular syphiloderm of this simple cha- 
racter the tubercles may slightly scale over, and then — or without 
scaling even — gradually lessen and disappear, leaving behind a 
slight stain or slight pitting : or they may increase in size, and 
suppurate : or run together into a small patch. In the next degree 
of intensity of the eruption, groups of tubercles are found here 
and there, forming distinct patches, the edge being bounded by 
well marked tubercles, the whole surface of the patch being scaly. 
The central portion may recover its normal appearance, save that 
it is dirty-looking, and somewhat atrophied, but there is a ring 
of tubercles as it were — hence the popular mistake of regarding 
the disease as ringworm. In some cases, indeed, the disease may 
make its appearance in rings, made up of circular lines of aggre- 



292 TUBEECULAE SYPHILODEEM. 

gated tubercles of granulation tissue, and patients will tell the 
physician, without being asked, that the disease began like a 
ringworm ; the dull coppery colour, absence of itching, and the 
general condition of the patient being at once significant of 
syphilis. Frequently the circumferential edge extends by the centri- 
fugal enlargement of the old, or the springing up of new tubercles ; 
the size of the patch augments, and the increase of the growth of 
new tissue, or infiltration, thickens the patch. In the most exagge- 
rated form of tubercular disease, the whole trunk may be affected, 
and then there is a mixed character about the eruption. It is 
made up in part of disseminated and distinct tubercles, small 
circular patches of aggregated tubercles, and lastly, large infiltrated 
patches, of greater or less degrees of thickness, in which the 
individual tubercles cannot be made out except at the very edge 
or around the edge. Now such patches are covered by thinnish, 
more or less adlierent scales, and hence the aspect is, to some 
extent, that of psoriasis. In certain places the disappearance of 
the tubercles has left behind distinct scars, of greater or less 
extent, and perhaps from their edges the formation of tubercular 
formations spreads away into the healthy tissue. The whole 
surface is muddy and cachectic ; the patient suffers from mucous 
tubercles ; gummata j)erhaps ; ulcerated tongue, tonsils and throat, 
alopecia; and other grave evidences of syphilis, and these con- 
comitant conditions vary in degree in different cases. 

The tubercles therefore may be disseminated, or arranged in 
the form of rings and groups, or crowded together into patches. 
But further changes than those just described may take place in 
tubercular syphilis, and they are mainly two — supjmration and 
ulceration. In regard to the former, it is only necessary to say 
that the tubercles in certain subjects, instead of being resorbed 
break up into unhealthy pus, and give out an ichor that dries 
into dark adherent crusts. Tubercular syphilis frequently ulcerates ; 
indeed, it has been usual to divide this form of syphiloderm into 
the ulcerating and the non-ulcerating / but these are not absolutely 
separated the one from the other. The non-ulcerating is the 
tubercular syphilis, as above described, the tubercles disappearing 
by resorption. The ulcerating form is simply ordinary tubercular 
syphilis running on to ulceration. 

In ulcerating tubercular syphiloderm the ulceration in one in- 
stance may be deep, and is called the perforating form ; in the other 
superficial, the serpiginous form. The first condition is the syphilide 
tuberculeuse perforante (perforating or deeply ulcerating tubercular 
syphilide). In it the tubercles are large, few, livid red, with a 
copper-coloured areola, having a tendency to ulcerate deeply, 
with accompanying pain and discomfort ; the ashy-coloured and 
foul ulcers, which may become confluent, crust over, the ulcera- 
tion meanwhile eating more deeply, the crusts being repeatedly 
shed and reproduced. In this way the nose may be destroyed 



SYPHILITIC ULCERATION. 293 

and lost, the disease resembling lupns : the disease is most common 
about the face. Severe ulceration is generally a symptom of 
tertiary syphilis, and accompanies marked cachexia, indurations 
of the periosteum, syphilitic caries, &c. When the ulceration is 
superficial it creeps along the surface, and then occasions what is 
called the serpiginous syphilide. It differs from the perforating 
variety chiefly in the fact that the ulceration takes place in a 
superficial manner, creeping over the surface ; the form varies 
somewhat — it may be in bands or circles ; the surface of the 
ulcer becomes covered over with blackish crusts, which fall and 
are reproduced from time to time ; the tubercles themselves are 
large, and, if the ulcers heal, distinct livid cicatrices remain 
behind ; if the tubercles become confluent, the ulceration is more 
marked. Another ulcerative condition is. the fissured tubercle ; 
it is smallish, but the seat of a linear ulcer, or a fissure in its 
centre ; it is accompanied by a good deal of pain, and a thinnish 
ichor is exuded from it ; it is seen about the side of the nose, lip, 
scrotum, and anus. 

A syphilitic lupus or lupiform syphilis has been described. The 
characteristic of lupus is the attempt at repair, which is so far 
successful that it gives rise to peculiar . indelible cicatrices, and 
when syphilitic tubercles are accompanied by a dull-red tint and 
succeeded by deep ulceration, with more or less scabbing, sanious 
discharge, and attempts at repair, ending in partial cicatrization, 
the disease has been termed syphilitic lupus ; but the term is a 
bad one, as likely to confuse between lupus and S} T philis. 

Diagnosis. — There is no difficulty in this. When an individual has 
tubercular syphilis, the evidences of active syphilis about him are 
mostly many and conclusive. The cachexia, the ulcerated tongue, 
the nocturnal pains, alopecia, buboes, gummata, mucous tubercles, 
and other signs and indications of syphilis are present to lead to 
a correct diagnosis. But the eruption itself is diagnostic. I 
know of no tubercle like the firm, not very vascular, copper- 
colon red tubercle of syphilis. Comparison is sometimes made 
between lupus and syphilis, but in lupus the tubercle is softer, 
more vascular, gelatinous-like. The lupus does not occur as a 
scattered eruption. It does not exhibit the same tendency to 
crust in connexion with sometimes slight infiltration, as does 
syphilis — a point upon which I lay much stress ; the ulcerations 
that succeed do not possess the features of syphilitic ulceration, 
to be noticed presently. The only difficulty arises where there is 
a single patch, or a patch or two, with no concomitants of syphilis. 
In such a case, if the tubercles are only slightly vascular and 
hard, I regard the case as one of syphilis, the more so if, in 
addition to a not excessive degree of infiltration, there is any 
tendency to ulceration and free crusting, because slight lupus 
does not ulcerate. If the disease has commenced in late life, that 
alone signifies that the disease is not lupus. But, after all, the 



294 SYPHILITIC ULCERATION. 

history and concomitants, and the plentifulness of the eruption, 
suffice to mark the disease as syphilitic as the rule. 

Syphilitic Ulceration. — This may arise from ulceration of pre- 
viously existing tubercular, or pustular or bullous syphilodermata, 
or as a consequence of the softening up of gummata, which are 
masses of syphilitic granulation tissue formed in the subcutaneous 
cellular tissue, in the form of hard indurated nodules, the size of 
from nuts to walnuts or more. If ulceration takes place the 
surface over these gummata becomes red and tender prior to 
ulceration, which is very indolent : and the resulting sore has no 
tendency to heal, but gives exit to a little fluid, scabs somewhat, 
and is not painful. 

Diagnosis. — Syphilitic ulcers are likely to be mistaken for lupus ; 
the former have shortly-cut edges, and the tubercles around are 
hard, smooth, dryish, dense, shining, and copper-coloured. They 
occur in people of middle age, are accompanied by concomitants of 
syphilis, and the ulcers are/old, dirty, ashy, exuding an ichor, and 
the tissues around are infiltrated and indurated ; in the lupus 
ulcer the edges are not sharply cut, but thickened and rounded ; 
there is no copper colour ; the tubercles are soft, red, quasi-gela- 
tinous ; the parts around are painful and oedematous ; it often 
occurs about the face alone in young people / there is an entire 
absence of syphilis, and the ulcers are clean and dry. 

Mucous Tubercles. — Just as there are growths and eruptions of 
the cutaneous, so are there similar affections of the mucous sur- 
face. It is only needful to refer now to those changes which are 
observable to the eye, and which are seated especially at the 
junction of the skin and mucous membrane, i.e., at the orifices of the 
natural outlets ; and not only may these growths form here, for 
any part of the surface which is habitually bathed in secretion, 
and acted upon by heat, is liable to the same kind of disease. 
This form of syphiloderma has been called vegetative syphilis, and 
is noticed mostly in the female about the vulva; in the child 
about the mouth, buttocks, and arms ; and the penis in the adult. 
There are two species — mucous tubercles and condylomata (warts). 
Mucous tubercles (see Elementary Lesions) are circular flat eleva- 
tions, of soft look and feel, and may be described curtly as warts 
formed out of mucous membrane ; they become more or less irri- 
tated, the parts around being also inflamed, at the same time that 
they give exit to a faint, pale, viscid secretion : they may ulcerate, 
or become pedunculated, when they are to all intents and purposes 
condylomata ; they frequently spring up in the seat of an old sore, 
and always cause considerable local discomfort. Condylomata are 
simply pedunculated little warts, occasionally sessile, differing 
from mucous tubercles in the fact of being firmer and not giving 
rise to ulceration or secretion. 

Syphilitic Alopecia is pretty common ; it occurs in connexion 
with the syphilitic fever in the early part of the disease, or the hair 



SYPHILITIC ONYCHIA. 295 

may thin out as a consequence of the establishment of cachexia, or 
it may fall off in patchy form as the result of ulceration. I have 
also seen it occur very commonly as the result of a seborrhoea set 
up, as it seemed to be, by slight infiltration about the sebaceous 
gland and hair follicles. The diagnosis is made by a process of 
exclusion, and the positive existence of latent or developed signs 
of syphilis. 

Syphilitic Onychia may attack the structure of the nail itself, 
or the matrix specially. In early infancy (under a year), sub-acute 
onychia attacks several fingers at one time in conjunction with 
iritis, otitis, snuffles, &c. Onychia is sometimes a secondary 
symptom in the adult : it ends in exfoliation of the nail, and is 
not unfrequently attended by a papular rash, &c, over the surface 
of the body. The local symptoms are pain, redness, swelling 
around the base of the nail, followed by suppuration and ulceration 
of the matrix, with loss of* the nail. Mostly the matrix escapes, 
then there is little pain ; and as Mr. Hutchinson described it to 
the Pathological Society, it begins at the root, where a "semi- 
lunar furrow is seen extending across it ; the outermost layer is 
destroyed over the entire lunula, and a ragged border overhanging 
that part is presented by the distal portion ; by degrees, as the 
nail grows, the diseased margin is pushed further and further on, 
The nails appear dry and brittle in texture, as is shown by the 
fissured and broken condition of the free edge." Several nails 
are attacked at the same time and that symmetrically; the pro- 
gress is very indolent indeed. I have seen now on several occasions 
the nail become the seat of a painful tubercle, which raises up 
the nail from its bed. I take it that this is merely the consequence 
of the presence of syphilitic infiltration in the matrix ; if the 
tubercle increases in size the nail is more and more detached, the 
whole nail-bed gets painful, the finger becomes club-shaped, 
and it appears as if the bone would necrose, but I have never 
seen the latter occurrence except as the consequence of onychia. 

In other cases of syphilis, the nails simply atrophy and are lost, 
as the result of cachexia, or they become ill formed, and friable, 
and stunted. 

Palmar and Plantar Syphilitic " Psoriasis" and Erythema. — 
These are important manifestations of syphilis in the skin, and for 
that reason I notice them specially. Now erythematous inflam- 
mation of the palms of the hands and the soles of the feet, of dull 
red colour, accompanied by slight infiltration and a certain amount 
of desquamation, or rather flaking off of the epidermis, is fre- 
quently part and parcel of congenital syphilis. Such a condition 
may also occur in the adult at an early stage, but my experience 
is that palmar and plantar mischief occurs later on in connexion 
with symptoms of long-standing disease, and generally speaking 
it takes the form of tubercular syphilis. Now there is one im- 
portant clinical statement that I venture to make here — that syphi- 



296 SYPHILITIC EXOSTOSIS. 

litic disease of the palm of the hand and the sole of the foot 
begins in these parts from a solitary spot generally in the centre, 
and spreads over their area by centrifugal growth, and is peculiarly 
localized to these parts, whereas non-syphilitic disease spreads to 
the palm and sole from adjoining parts. As the rule a brownish 
spot, or, it may be, corn-like but reddish induration, or button- 
like infiltration, appears about the centre of the palm or the sole as 
the case may be ; it may scale over. It increases in size, and 
may crack ; by-and-by when a patch is formed it looks like 
psoriasis, but the central part heals up, only being a little thinned, 
whilst the epidermis forms a whitish rim around, peels off and curls 
back, in fact, from the extending infiltration. The patch enlarges 
and creeps farther and farther over the surface, sometimes in the 
form of rings, the central part clearing as regards the redness, 
but remaining dry and discoloured. 

The surface of the disease may not only be cracked, but tender 
and more or less irritable. Perhaps when the whole palm is 
invaded, the disease may break up into islets of disease by the 
healing of the palm in parts only ; and then — i.e., in connexion 
with old-standing disease, little knotty tubercles may appear about 
the fingers, especially the index finger, on the side next the 
thumb ; but not here and alone, the knuckles may be attacked, 
and the parts are dry, harsh, knotty, reddened, and fissured more 
or less. 

Another phase is not a red erythematous or tubercular condi- 
tion of the derma of the hand and foot, but a hard, corn-like 
general thickening with rissuring. There is in connexion with the 
forms of disease now under notice concomitant evidence of 
syphilis and particularly ulceration of the tongue — in fact, a 
thickened and reddened scaly state of the palm of the hand, or 
sole of the foot, with a sore tongue, is absolutely certain to be 
syphilitic and nothing else ; and this leads me to remark that I 
have never seen a case of uncomplicated non-syphilitic palmar 
psoriasis. I have seen ringworm on the w T rist extend to the palm 
of the hand and induce a state of things like it, and eczema also, 
and disorders of sweat glands also ; but I hold that a reddened, 
thickened, scaly appearance developed primarily in the centre of 
the palm of the hand, may for all practical purposes be regarded 
always as syphilitic. 

Syphilitic Exostosis. — About two years ago I was consulted by 
an American gentleman for a peculiar complaint, for the relief of 
which he had consulted some twenty-one medical men in America, 
France, and England without benefit." He had indeed suffered 
many things of many physicians, and was none the better, but 
rather the worse. I. found him in bed, pallid, nervous, irritable, 
and prostrated. He told me he could get no sleep whatever at 
night, as he had such agonizing pain in his head, his neck, his 
legs, and his sides. My attention was directed to his forehead, 



DACTYLITIS SYPHILITICA. 297 

which presented two flattish oval bony projections a few lines 
high ; to one of his clavicles, which was greatly enlarged, its sternal 
end being twice its usual size and projecting upwards most incon- 
veniently; to his tibia, upon the front of which about its middle 
and above were seated two distinct nut-like hard prominences ; and 
to his ribs, some of which presented similar enlargements. I 
regarded these outgrowths as exostoses for the moment, as others 
had before, and 1 found my patient had taken an enormous 
amount of iodide of potassium. On inquiring into the history of 
the case it turned out that these apparent exostoses came in the 
first instance as sof tish lumps, and it seemed to me that they had 
developed out of a periostitis. I then found that the patient had 
had syphilis some eight or nine years before badly, and had not 
been well since. I finally concluded that the whole thing was 
syphilitic, and decided to mercurialize the patient, who was taking 
forty and more grains of chloral, opiates, and other things at night. 
However, the case seemed to me so clear, and yet no one had before 
held my view of the case, that I asked Sir William Jenner to see 
it with me, and he agreed in my view. We gave bichloride of mer- 
cury with large doses of sarsaparilla. In a very little time the 
pains went, the swellings disappeared, the patient gained flesh, 
and he has since been over from America to see me, and reports 
himself never better in his life. The cure, I confess, astonished 
even me by its rapidity and completeness. This outline perhaps 
will do more to give an idea of a condition of bony formation that 
may sometimes occur late on in the history of a case of syphilis 
than any detailed or set description I could give. The fact that 
the disease arises as a periostitis is the diagnostic point. 

Dactylitis Syphilitica. — This is a tertiary disease of the fingers 
of considerable clinical interest. The best account is that given 
by my friend Dr. E. W. Taylor, of New York.* It is a disease not 
of the superficial, but the deep parts— the bones and their fibrons 
coverings — of the fingers and toes. The disease is due to the 
formation of syphilitic granulation tissue (gummy deposit) in these 
parts. The patient in whom the disease occurs always affords a 
syphilitic history, and the lesion under notice follows the events of 
the secondary period, and, as far as has been observed, mostly 
occurs in close connexion with other signs of tertiary syphilis. 

The gummatous material may be deposited mainly in " the sub- 
cutaneous connective tissue, as well as the fibrous structures of 
the articulations and the phalanges," or the morbid process may 
" begin in the periosteum and bones, and secondarily implicate 
the joints, and may or may not be accompanied by deposit in the 
subcutaneous connective tissue" (Taylor). But this division of 

* See the American Journal of Syphilography and Dermatology, Jan. 1871, in a 
paper in which every possible reference to authorities is given. See also a case 
recorded by Dr. Wigglesworth in the same journal, for April, 1872. 



298 DACTYLITIS SYPHILITICA. 

the cases that have been observed into two classes is " quite arbi- 
trary," yet it is clinically convenient. 

The variety that begins superficially, to use Dr. Taylor's words, 
generally " consists in a copious gummy deposit, both in the 
connective tissue and the fibrous structures of the joints, with sub- 
sequently a much less copious deposit in the phalanges. It may 
be developed in a single finger or toe, or it may involve more than 
one of either of these members, and may even involve one or more 
of each at the same time. It usually attacks but one joint, and 
in all but one of the recorded cases — in which it occurred in the 
second — it has been the first phalangeal joint." The deposit is 
more marked on the dorsal than the palmar or plantar aspects of 
the hands and feet, and " at the metacarpal or metatarsal phalan- 
geal articulations ; it shades off abruptly into the integument of 
the hand or foot, forming " a ridge or " a ring." The disease is 
quite different from syphilitic paronychia, in which the matrix is 
inflamed and u.lcerated. It develops itself very slowly, and runs a 
very chronic course. The lesion shows little tendency to dis- 
organization or necrosis. The growth always feels hard and 
resistant, and is not lax or moveable. The integuments are of a 
livid reel colour, and this persists for a considerable time until 
cure approaches. The ligaments are eroded by the deposit of 
gummatous material and its subsequent removal — hence they appear 
worm-eaten. The swelling may thus be confined to one phalanx, 
it may shade off into or wholly involve the second, or may uni- 
formly enlarge the whole of the finger or the toe. " This 
variety differs from the second in the fact that the principal deposit 
is in the connective and fibrous tissues, whereas in the latter the 
principal seat of the morbid process is in some portion of the 
bone. The clinical facts which are now in our possession do not 
allow us to state decidedly that the lesion of the bone only pro- 
gresses to a very moderate degree, as shown by a not very ex- 
tensive enlargement of those structures in recorded cases," for 
the simple reason that anti -syphilitic treatment has been adopted 
at an early stage. 

But repair takes place in some cases, in others there is much 
deformity induced, but this results chiefly from the implication of 
the joints in the disease, which a-re the seat of crepitation, in some 
cases due to the impaired nutrition of the cartilages, if not erosion. 
The final stage of the disease may leave the joint slightly, if at 
all, injured or distorted. The movements of the joints are 
much impeded during the period of greatest deposit. The ac- 
companying figure (28) represents a toe affected in one of Dr. 
Taylor's cases. 

The infiltration was so copious that even long-continued firm 
pressure failed to clearly reveal the condition of the bones, but 
the joint structures and the first and second phalanges were noticed 
to be considerably enlarged, and the first phalanx was thought to 



DACTYLITIS SYPHILITICA. 



299 



be more enlarged than the second. Pain was net present ^ in the 
toe, neither was it produced when the integument was pinched, 
nor when the lateral surfaces of the joints were pressed, nor when 

Fig. 28. 




their articular surfaces were firmly shoved together. The length 
of the toe was normal. 

Fig. 29 shows the deformity finally produced in a hand. 

Fig. 30. 



Fig. 29. 





(After Volkmann. ) 



One of Berg's cases. 
The second clinical variety commences as a periostitis, or as an 
osteo-myelitis. Dr. Taylor says : — 

" The swelling- of the fingers and toes in this variety is very considerable, so that 
in Berg's case the circumference of a finger at the first phalanx was nearly five 
inches. As the principal lesion is in the bone and joint-structures and only ex- 



300 DACTYLITIS SYPHILITICA. 

ceptionally under the integument, the enlargement is nearly limited to the pha- 
langes which are involved. The recorded cases show us that any, or all of these 
phalanges may be attacked by this process ; the process may be slow in develop- 
ment, or it may run an acute course. In the thumb of a patient of Volkmann's the 
first phalanx slowly enlarged, and thus remained a year, before the second was 
involved, whereas, in the same patient, other fingers swelled so acutely that it was 
necessary to make incisions into them. So we may conclude that the acute and 
chronic course may exist in the same patient. 

" The integument becomes very much stretched by the pressure from within, 
and the surface-markings and articular furrows in it are effaced, and it can only 
with difficulty be pinched between the fingers, and it may be so very tense that it 
can scarcely be moved over the parts beneath. Its colour varies from a pink to a 
decided red, and when the lesion of the bone has been very acute, it may become 
very much tumefied and sensitive; but this condition is only temporary. In this 
variety, as in the first, there is no concomitant lesion of the nail, even when the 
last phalanx is involved. The gummy deposit does not, as a rule, exist under the 
skin in this variety, though in one of the fingers of Volkmann's patient, upon 
incision, it was found there in very small quantity." 

The final result is the destruction and removal by interstitial 
absorption of the bone, the whole or part of the shaft attacked, the 
finger being left shortened and deformed. There is no suppura- 
tion. When the disease runs an acute course the swelling is not 
so hard as in the chronic disease. 

Thus dactylitis occurs in connexion with other tertiary lesions, 
it has as its accompaniment the evidences of the syphilitic cachexia, 
it is a disease of mid and late life, but may also occur in the young. 

Diagnosis. — Dactylitis might be confused with chronic rheu- 
matic arthritis, paronychia, strumous disease, enchondroma, ex- 
ostosis, and periostitis. The concomitants, and the history of the 
case, and the painless nature of the affection, would invariably save 
from error. 

GENERAL REMARKS ON THE FOREGOING ERUPTIONS. 

It will be evident to the reader, if he reflects upon what has 
been said as to the seat of the morbid processes in the foregoing 
description of the eruptions, that there are in syphiloclermata the 
same type of changes as occur in the ordinary inflammatory diseases 
of the skin, except that in syphilis a new and special kind of tissue 
is formed. I am by no means sure that a pathological division of 
syphilitic eruptions is not the best and most convenient, commencing 
with hyperemia of different parts in the first instance, and passing 
through the period and phases of infiltration, and subsequently 
resorption or degeneration of the infiltrated product. In fact, 
syphilodermata may be divided, for all practical purposes, into three 
groups — (a) those which are hypercemic / (b) those that have de- 
posit (or new tissue formation) as the main feature — i.e., depositive / 
and (c) degenerative lesions, the result of suppuration aud ulcera- 
tion of the syphilitic new tissue formed in tlie skin. 

The first effect of the syphilitic poison upon the general system 
is to give rise to sypliilitic fever, and, together with this, transi- 
tory hypersemic lesions show themselves, as in roseola and ery- 
thema. Sufficient time having elapsed for the operation of the 



SYPHILITIC ERUPTIONS. 301 

syphilitic poison upon the nutrition of the textures, modifica- 
tions of their normal growth take place — that is, new tissue is 
formed — viz., granulation tissue or syphilitic tissue, which appears 
in the form of papules, tubercles, mucous tubercles, gummata, &c. 
Meanwhile the syphilitic poison, circulating through the glands, 
has inflamed them, hence the occurrence of syphilitic acne ; and 
the follicles — hence syphilitic lichen. These diseases commence in 
hypeimmia of the follicle and sebaceous glands respectively, but 
the hyperemia is not now transient, but is succeeded by infiltra- 
tion of granulation tissue into and about their parietes. At the 
same time the nerve trunks may become irritated by the poisoned 
blood or deposit about them, and herpes and pemphigus occur as 
a consequence. The further stage of syphilis of the skin consists 
in the infiltration by the syphilitic granulation tissue of the deeper 
parts, and more extensively than at an earlier stage of the super- 
ficial parts, whilst the patient's general health becomes cachectic ; 
and the syphilitic tissue softens up and suppurates or ulcerates — 
in fact, this latter stage is characterized by degenerative changes 
in the syphilitic deposit in different parts. I may chart out what 
I have just said as follows : — 

1st period* — Syphilitic fever with, in the skin, transient hyper- 
emia, giving rise to roseola, etc. 

2nd period, — Essentially characterized by the formation of syphi- 
litic tissue and the occurrence of hyperemias, which are not 
transient, but are followed by infiltration, and include 

(a) Hyperemia of, and infiltration about, the sebaceous 

glands — syphilitic acne. 

(b) Hyperemia and deposit in the hair follicles — syphi- 

litic lichen. 

(c) Ditto in the derma — papular and tubercular, squa- 

mous and pustular syphilis. 

(d) About the nerves — syphilitic herpes and pemphigus. 
3rd period. — Characterized by changes — ex. gr., ulceration, &c, 

in pre-existing syphilitic formations, which lead to syphi- 
litic ulceration, exostosis, &c. 



* Founder, of the Lourcine Hospital, in Paris, has called attention to the fre- 
quent occurrence in secondary syphilis of the existence of insensibility to pain 
(analgesia) in the skin. This phenomenon is one of a variety of alterations of 
sensibility, Fournier affirms, which occur especially in women who are syphilized. 
The most common form of the disorder is localized analgesia, the patient being 
conscious of contact of heat and cold and the like. In other cases this analgesia 
is linked with more or less anaesthesia. But the latter does not exist without 
the former. In some instances the patient is analgesic and the sense of appreciat- 
ing differences of temperature is lost. The commonest seats of the local analgesia 
are the lower parts of the legs, the feet, and the bands ; the back of the hand is 
often alone affected ; in fact it is in the latter situation that the analgesia must first 
be detected; and the analgesia is symmetrical, it is superficial (cutaneous truly so 
called) and most persistent in this locality. The occurrence of analgesia is coinci- 
dent with the early development of secondary syphilis. The disturbance of sensa- 
tion may last for weeks or months. — Boston Medical and Surgical Journal, April 14, 
1870 ; paper by Dr. "Wigglesworth. 



302 



PATHOLOGY OF SYPHILIS. 



The main thing in all cutaneous manifestations of syphilis is, 
after all, the production of new tissue of special kind, aud it is to 
this and the changes it undergoes that I always direct the student's 
attention. 

Fig. 31. 




¥-e 



- 

- - . - - ■ . . . 







x 300. (After Auspitz ) 

Vertical section through a syphilitic induration, a. Horny layer of 
epidermis. b. Eete Malpighii. c. Cutis, d. Papillas filled with cells 
that appear to be continued into the cellular mass of the rete, making 
the outline of the papillae indistinct, e. Cut connective-tissue bundles. 

Morbid Anatomy and Pathology. — The main change found in the 
skin in syphilis is the formation of a new cell growth or granulation 



PATHOLOGY OF SYPHILIS. 303 

tissue. This new growth is made up of cells that structurally 
differ in no respect from those of lupus, and the description given 
of the cells of the new growth in lupus (see Elementary Lesions, 
p. 42) will apply equally well to the anatomical characters of 
those of syphilis. If the tissue of a hard induration be examined, 
the rete Malpighii will be found to be swollen by proliferation of 
its cells, which may presently undergo fatty degeneration, whilst the 
cutis is the seat of cell infiltration, pretty generally distributed along 
the vessels and in the meshes of the connective tissue (see fig. 31). 
There are additional changes induced by alteration in this deposit ; 
for instance, on the removal of syphilitic indurations, there is the 

Fig. 32. 







£•„--'.-:- - __ ■_ . - 



mm 



?-: 



xlOO. (After Auspitz.) 

Oblique section through the edge of a syphilitic ulcer of the scalp. 
a. Epidermis, b. Papillae cut in all directions : many atrophied, c. Di- 
lated hair bulbs with external sheath of the root, d, Surrounding 
follicular wall, having in its interior partly disintegrated cells. 

formation of scars, involving atrophy of the corium to a greater 
or less degree. The illustration (fig. 31) given by Dr. Auspitz 
may serve to portray the kind of infiltration which takes place 
in the skin in syphilodermata generally," for the new cell 
growth is the same in them as in the chancrous syphilitic in- 
duration. 

In the papule and tubercle of syphilis of the skin, where the 
disease is marked, the cell growth is found to be very plentiful 

* Ueber die Zellen-infiltrationen der Lederhaut bei Lupus, Syphilis, und Scrofu- 
losis. Von Dr. H. Auspitz (mit Tafel). Separat-abdruck aus den Med. Jahr- 
bucher, 2 Band. 1864, 



304 TREATMENT OF SYPHILIS. 

between the fat cells of the paniculus adiposns. The papillae are 
sometimes greatly enlarged and elongated, and in the case of con- 
dylomata, which are essentially tubercles, they are much branched. 
Where the disease is severe, the meshes of the connective tissue 
are enlarged and greatly distended by collections of cells. When 
the syphilitic new formation undergoes resorption, and especially 
after ulceration takes place, there is atrophy of the corium 
produced, with destruction of hair follicles, glands, and papillse, 
as in lupus, and as seen in fig. 32. 

Auspitz remarks that, in the case of syphilitic ulcers, the same 
changes are found as in the lupus ulceration about the walls and 
the base of the nicer. In the instance of pustular syphilis, the 
cell infiltration is accompanied by changes in the rete Malpighii 
similar to those observed in the pustule of small-pox — that is to 
say, loculi are formed in the rete by fibres formed from st retch ed- 
out cells, and enclosing pus cells. It will be readily understood that 
in proportion to the degree of cachexia or mal-nutrition, the 
normal textures will tend to soften up, to suppurate, or to ulcerate, 
as the case may be, in connexion with the invasion of these 
structures by the new growth. 

Diagnosis of the Sypliilodermata. — This has been sufficiently 
dealt with under the head of individual eruptions, and in the 
opening remarks. (See p. 280.) 

Treatment. — I know of no disease in regard of which it is more 
important to remember that the treatment of the disease is one 
thing, the treatment of the patient another ; and that the proper 
treatment required to relieve an individual of his disease must be 
a combination of those remedies which are calculated to combat 
the diseased processes themselves, and those which remedy con- 
ditions belonging to the individual himself, which tend to modify 
these morbid processes. Syphilis in a person of nervous tem- 
perament, on the one hand, and scrofulous habit on the other, is 
not quite the same thing : nor in the private patient on the one, 
and the half -starved hospital out-patient on the other. It is 
necessary, in fact, to treat the disease and to treat the patient also 
at the same time. In dealing with this matter I of course take 
up the question of treatment in relation to secondary and tertiary 
disease only. 

The Treatment of the Patient. — The syphilitic fever is a great 
depressant ; it unfits the individual in whom it occurs for active 
work, and, in my opinion, should lead the physician to prescribe 
perfect quiet and rest for some days, to be followed by the pre- 
scription of change of air for a week or ten days if possible. The 
patient should adopt a cool regimen, avoid wine and beer at first, 
be careful not to catch cold, and should live plainly. In this way 
the physician places the patient in the most favourable condition to 
recover speedily and in the best possible manner from the attack. 
If the patient be one of the middle or upper classes, it may be all 



TREATMENT OF SYPHILIS. 305 

the more necessary to " cut off the supplies ; " but if he be a 
hospital patient, ill-fed and ill-clad, it is all the more necessary to 
enjoin rest, and to commence from the outset a tonic plan of 
treatment, and as far as possible to augment the quantum and 
improve the quality of the diet. 

As the disease advances these several points acquire greater im- 
portance. The luxurious life, the over-eating and over-drinking 
of many of the rich, are as antagonistic to the favourable progress 
of syphilis as are the want and uncleanliness of not a few of the 
lower orders. In my experience the influence of alcoholics on the 
course and character of syphilitic lesions is very great indeed. Free 
indulgence in alcoholics implies, as the rule, a lack of good solid 
food, and not seldom debauchery in theindulger ; and under these 
circumstances cachexia is more speedily developed. Another 
cause which I think considerably modifies the aspect of syphilis of 
the skin is a scrofulus disposition. The tubercles of syphilis 
tend to suj3purate and to ulcerate, it seems to me, very readily in 
such subjects. 

Bad living, mal-hygiene, indulgence in alcoholics, and the 
strumous habit of body, are the chief peculiarities in the indi- 
vidual that demand special treatment in connexion with syphilo- 
dermata. The means for remedying these mal-influences are self- 
evident, the strumous tendency calling for good food, iron, quinine, 
and cod-liver oil at an early stage of the disease. 

The Treatment of the Disease itself. — Dermatologists possess 
no remedy which they can introduce into the system to neutralize 
the syphilitic poison. They can only keep in check, and quicken 
the removal of, the results of its operation upon the nutrition — the 
formation of the. new cell growth. But more than this — it is pos- 
sible to thwart, by the judicious exhibition of a tonic treatment, 
dietetic and medicinal, the occurrence of ulcerative changes in the 
neoplasm. 

The remedy for all syphilodermata is of course mercury* except 
in those cases in which, the drug may, in consequence of the 
existence of cachexia, still further depress. In these cases, and 
those of tertiary syphilis, empiricism has taught us that the 
appropriate remedy is iodide of potassium. 

Different explanations are given of the action of mercury. The 
drug increases the action of the natural emunctories — notwith- 
standing Dr. Hughes Bennett and his experiments on healthy dogs — 
and it in part so far does good. But it would seem to act by caus- 
ing absorption of morbid tissue — such as inflammatory products, 
syphilitic tissue — more speedily than that which is normal, for 
it must be remembered that mercury acts very salutarily in cases 
of chronic inflammatory thickening, as in chronic eczema, psoriasis, 
sycosis. Mercury, when given freely and persistently, causes 
softening and absorption of normal tissue — ex., the gums, and it is 
quite conceivable that the kind of action exhibited towards the 
20 



306 TREATMENT OF SYPHILIS. 

normal tissues may be much more active quoad diseased tissues, 
because the latter must possess less of that power to resist morbid 
changes under the influence of chemical and other agencies acting 
upon them than do healthy tissues. Now naturally, in persons 
broken down in health, in whom there is much suppuration or 
tendency to " unhealthy " ulceration, the normal resistant power 
of the tissues is lessened in amount, the whole tissues exhibit a 
marked disposition to soften up and degenerate, and consequently 
the action of mercurials may be bad instead of good. Under such 
circumstances as these, if mercury be given, it must be given 
cautiously, and be combined with potent tonics ; but I invariably 
combine quinine, and frequently iron, with the mercurial which I 
give to patients, and I think with decided benefit. But in so- 
called tertiary syphilis, the deposit may be slight, whilst the un- 
healthy behaviour of the surrounding tissue explains the rapid 
extension of ulceration. Mercury is of course not called for in 
this case. Hence theoretically the drug is of use where the for- 
mation of new tissue is marked, and does not show any tendency 
to freely suppurate or ulcerate, and the patient is not cachectic. 
Mercury is to be avoided where the deposit is slight, or rapidly 
degenerates, or in persons markedly cachectic. I cannot explain 
the action of iodide of potassium except that it acts on the glan- 
dular system, increasing resorption of infiltrations, and so does 
good in cachexia, whilst mercury influences directly the new- 
formed tissue. There are cases which occupy a medium position, 
in regard of which it is not possible to say whether mercury 
or iodide of potassium will act the better of the twain. There are 
some cases especially of tertiary or deeply-seated disease inpatients 
who have been under the influence of iodide of potassium for a 
long time, and who are not cachectic or debilitated to any great 
degree, that are at once benefited, and occasionally marvellously 
so, by a mercurial course. I have seen many such cases. But in 
some instances of syphilodermata the combined use of mercury 
and iodide of potassium is of much value ; in fact, in well marked, 
wide-spread tubercular syphilis, this is the treatment I adopt. 
Salivation should never be produced. It is unnecessary. 

Eow as to the mode of administering mercury and iodide of 
potassium. I have for years discarded the bichloride, blue pill, 
and all other preparations of mercury, and I now use the bicyanide 
exclusively. I give it in pill, beginning with gr. -g- 1 ^, with extract 
of gentian, quinine, or opium, as the case may be, twice a day ; 
whilst iodide of potassium, in five-grain dose, at first twice and 
soon thrice a day, with spirits of ammonia, is given internally ; 
and each dose about three hours after each pill. In this way I get 
the full effect of the iodide of mercury without upsetting the 
stomach by introducing the compound into it. The mercurial 
may be coutinued until the disease goes — say in a month or six 
weeks, or until the gums show signs of becoming spongy. Sali- 



TREATMENT OF SYPHILIS. 307 

nation should not be induced, If the disease be extensive, the 
calomel vapour-bath twice a week may be administered. This is 
my usual treatment, and I am quite satisfied with it, especially 
with the action of the bicyanide, which is a more soluble compound 
than the bichloride, and has none of the irritating qualities of the 
iodides. I never produce salivation, nor other serious "mer- 
curial " sequences ; and the bicyanide, given alone in the slighter 
forms, acts most effectual^. The iodide of potassium is given 
with it at once, when the disease is papular, tubercular, or pustular, 
and general over the body. 

If the patient be much debilitated the action of the mercurial is 
to be watched, if anaemic iron may be combined in full doses with 
the iodide of potash. It may be continued until the disease disap- 
pears or is disappearing, and then iodide of potassium substituted 
for it. If the gums get spongy the drug must not be taken, or 
only in diminished doses. 

Inunction is another mode of exhibiting mercury, but it is only 
of use in infantile syphilis, except where disease is rapidly spread- 
ing, and it is desirable to make a very rapid impression upon it. 

Speaking generally, I may say, by way of summary, in the 
papular, tubercular, squamous, and pustular syphilides mercurial 
treatment is called for. In the ulcerating forms, if the patient be 
well nourished and pretty strong, there is no objection to a mer- 
curial course ; but where cachexia is marked, and the patient's 
condition is one of evident debility, iodide of potassium with cod- 
liver oil, or iodide of iron and good food, constitute the best 
treatment. 

In cachectic subjects who are debilitated, restless, and irritable, 
opium given internally is of much service. In reference to iodide 
of potassium it must be borne in mind that its use is beneficial in 
direct proportion to the duration of the disease ; hence when 
nodes, tubercles, caries, and secondary ulcers are present, when mer- 
cury has been fully used, or seems to fail. 

The dose should be gradually increased by three or four grains 
every few days, until in the case of old-standing and ulcerative 
syphilis it reaches thirty or forty grains. 

hi most cases the exhibition of decoction of various woods is 
advisable. The compound decoctions of sarza and guaiacum are 
the best ; they keep the skin and bowels freely acting, and thus 
very materially help the elimination of the poison. 

When a patient is under the influence of mercury, he should 
avoid stimulants, cold, and other sources of irritation and catarrh. 

The administration of mercury should always be followed up 
with a course of mineral acids and bitters, or iron and quinine, or 
other suitable combination. 

Mercurial fumigation, which acts both locally and generally, is 
in great favour with some practitioners. It involves a great deal 
of trouble and inconvenience, and the process is often long over 



308 TREATMENT OF SYPHILIS. 

its work. I think my cases do quite as well if not better without 
it, and I do not largely employ the calomel vapoiir-bath. In 
giving a mercurial bath, the patient is seated upon a chair and 
covered with flannel, and outside this by an oil-silk quasi-eoat or 
bag ; beneath the chair is placed a copper-bath, containing a pint 
or somewhat less of water; upon this is placed a tinned iron plate, 
which holds the mercury to be sublimed ; beneath the bath is 
placed a spirit-lamp ; the patient, after the latter is lighted, is 
u exposed to the influence of three agents — heated air, common 
steam, and the vapour of mercury ; in about five minutes perspi- 
ration comes on, and the patient should be subjected to the in- 
fluence of the bath for some ten or twenty minutes, when the 
lamp should be removed, the patient allowed to cool gradually, 
and made to take," as Mr. Parker further observes, " a warm drink 
of decoction of sarza or gnaiacum." 

If the preparation employed be the bisulphuret of mercury, 
about one or two drachms should be used ; if calomel, from ten to 
twenty grains ; if the iodide, ten to twenty grains ; the oxides 
and the bisulphnret are the mildest; the iodides the strongest 
f umigants. The bath may be used once, twice a week, or even more, 
according to circumstances. 

The Zittmann Treatment. — Continental dermatologists advocate a 
plan, which Wilson briefly defines as "a triple compound of 
starving, purging, and sweating," and which he mentions with 
commendation ; it is the so called Zittmann treatment, but is one 
which compels the patient to give up his usual employment, to 
take to bed for a fortnight or so, and on this account is almost 
inapplicable in a general way. I have used it with benefit in old- 
standing disease, in which iodide of potassium did not act well. 
The patient who has syphilitic disease wants to get rid of it 
without entering upon any plan of medicine which would disclose 
his secret, and take him away from his work ; most men could 
not afford the time : however, the plan is as follows : — First day, 
a purge (calomel and jalap), and three meals of broth ; up to the 
fifth or sixth day four pints of the Zittmann decoction are taken 
daily — of these four pints two are made of the strong and two of 
the weak decoction {vide Formulary, No. 166) — with each day two 
ounces of meat and two of bread ; on the sixth day an active purge, 
with broth as before ; the seventh till tenth repeat the drinks, and 
meat and bread ; this continues till the fourteenth day or so, and 
then the patient is kept on low diet, allowed to get up, but still con- 
tinues to take a small quantity of the decoction. If convalescence 
is tardy or insufficient, the same treatment must be recommenced. 

It has been a matter of much dispute whether infantile syphilis 
should be treated upon similar principles to those above described. 
For my own part, I should be exceedingly sorry to be an infant 
affected by specific disease and not treated by the drug mercury, 
in addition to chlorate of potash, and syrup of iodide oi iron. 



TREATMENT OF SYPHILIS. 309 

The best plan is to rub a little mercurial ointment into the sole 
of one foot at night, and where the nurse or mother is tainted, to 
give the iodide to her, and therefore to the child through her milk. 
The mercurial requires to be used only a few times, and at each 
rubbing a piece of ointment about the size of half a pea suffices. 

Treatment of syphilis by hypodermic injection of mercury has been 
advised. This plan was first adopted by Dr. Lewin, of Berlin, but it 
is of very inconvenient application. Dr. Taylor, of Kew York, as the 
result of his trials, says that an injection of an eighth of a grain of 
bichloride of mercury every second day for two or three months is of 
value in all the secondary periods of syphilis, in syphilitic neuroses 
and cachexia, and early tertiary disease, but not in bone disease 
or mucous-membrane trouble. But relapses are as frequent with 
the hypodermic as with other plans of treatment, and there are 
local effects, such as pain, induration of the connective tissue, and 
abscesses. Dr. Wigglesworth has also written ably on this sub- 
ject.* The best seats for injection are those where the skin is 
most moveable and most readily thrown into folds — ex., the sides 
of the chest, the hypochondria about the back, and the nates near 
the crests of the iliac bones. The parts near lymphatic glands are 
to be avoided. Dr. Lewin suggests the use of a solution of 4 grains 
to the ounce, the dose being from 8 (y 1 ^-) to 24 (gr. -J-) drops. 

" The best syringe for injecting is made of hard indiarubber, as 
this is least readily attacked by the corrosive drug. The measure- 
ment of its contents should be made in grains rather than in drops. 
The exact dose administered should always be known. The bore 
of the syringe should be everywhere the same, and the piston 
exactly fill it. The canula should have a point like a pen, for if 
lance-shaped the pain of extraction is greater than that of insertion. 
This point must be as small and the canula as smooth as possible. 
Careful cleansing of the canula and occasional sharpening of its 
point are necessary to preserve them from the action of the 
sublimate. With care one canula will suffice for one hundred 
injections. As a rule, one injection per diem is sufficient, though 
the administration of two seems sometimes to hasten the cure. A 
fold of the skin is to be raised between the thumb and forefinger 
of the left hand; the canula should be inserted quickly and 
through the cutis into the subcutaneous cellular tissue, and then 
pushed well in. During the injection the point of entrance of the 
canula should be covered with the left forefinger, and the canula 
itself gradually withdrawn, so that its point at completion of the 
injection shall be near the place of its insertion into the skin. 
On the removal of the canula, the forefinger, before quitting the 
skin, should press and rub the wound slightly to one side, as this 
prevents loss of the injection or of any blood. The wound may then 
be covered with a bit of plaster. With regard to diet, clothing, 

* Boston Medical and Surgical Journal, Aug. 26 and Sept. 2, 1869. 



310 LEPROSY, OR ELEPHANTIASIS GR^CORUM. 

bathing, &c, this mode of treatment requires no departure from 
usual habits."* The method is not increasing in favour, however. 
The Local Treatment of ' Syphilodermata.— -The erythematous forms 
require no special application. I often use an oxide of zinc lotion, 
coloured with calamine. If they be obstinate and leave behind 
any papules, a white precipitate ointment may be used; the squa- 
mous and papular eruptions are relieved by calomel ointment, 
bichloride lotion, and nitric oxide of mercury ointments. - The 
tubercular and ulcerating forms of disease are those which require 
special local medication. In the tubercular form mercurial oint- 
ments — ex., weak nitrate or nitric oxide — are those most especially 
useful : acid nitrate of mercury may be used cautiously to destroy 
obstinate indurations. Syphilitic ulcers may be dressed, if 
painful, with a solution of watery extract of opium, or be dusted 
over with calomel, or be stimulated with the nitric oxide of 
mercury ointment, dilute nitric acid and borax lotions, or treated 
by the local application of mercurial vapour. If they are very 
foul or dirty-looking I prefer dressing them with iodide of starch 
to any other treatment. After a while a clean sore is produced, 
which may be dressed with a weak mercurial application or an 
astringent w^ash. In the appended Formulary several remedies 
will be found in reference to the general and local treatment of 
syphiloderma. See numbers 17, 21, 23, 24, 49, 94-5-6-7, 98, 
99, 126, 132, 135, 141 et seg., 166, 179, &c. 

LEPROSY, OR ELEPHANTIASIS GR^CORUM. 

Under this head I include the true leprosy, or Elephantiasis 
Grsecorum, known in India as Kakta-piti ; in Arabic as Jazam or 
Juzam. The disease of the leg known as elephant leg, or elephan- 
tiasis Arabum, and now called bucnemia tropica, or pachydermia, 
has no true relation to leprosy. 

The best information we possess with regard to the disease is 
contained in the Leprosy Eeport (1866) of the College of Physi- 
cians. But there are also a host of scattered papers, in various 
publications, of great interest. f 

Its geographical distribution is most extensive : the chief seats 
of leprosy in recent times continue to be the same regions of 

* See Wiener Medizinische Presse, Nos. 17, 20, 24, 28 ; 1868. 
f See (1) the Half-yearly Customs Reports issued by the Inspector-General at 
Peking-. (2) A series" of papers in the Indian Medical Gazette, 1866, by Mr. 
Macnamara of Calcutta, being an analysis of reports of 107 medical officers in the 
East Indies, in reply to interrogations officially submitted to them. (3) Essai 
sur 1' elephantiasis des Grecs, et sur l'elephantiasis des Arabes, par Br. Brassac, in 
the Archiv. de Med. Navale, 1866 and 1864, &c. &c. (4) The work of Brs. 
Banielssen and Bock. (5) Indian Medical Journal, Jan. 1866, et seg. (6) Scheme 
for Obtaining a Better Knowledge of Endemic Skin Biseases of India, prepared for 
the India Office by Br. Tilbury Fox and Br. Farquhar, 1872. (7) Report on the 
Prevalence and Characters of Leprosy in the Bombay Presidency, from Bombay 
Med. and Phys. Soc. Trans., vol. xi., 1871, by Br. H. Vandyke Carter; and a 
paper in vol. viii., 1862, by the same gentleman. 



311 

Africa and Asia where it was originally seen, and where it is 
known to have been most common in remote ages. It prevails 
in Egypt and on the shores of the Mediterranean and Red Sea ; 
in Abyssinia, the north coasts of Africa, in Algeria, and at Mo- 
rocco and Senegambia ; at the Cape, Madagascar, in the Mau- 
ritius, and the Isle of Bourbon ; in the Asiatic continent ; in 
the southern parts of Syria, about Beyrout, at Jaffa, at Nablus ; 
in Arabia, and parts of Persia, Bokhara, Cashmere ; in India, 
along the sea-coasts, in all the Presidencies ; in Ceylon (its 
southern parts) ; in Java, Sumatra, and other islands of the Indian 
Ocean ; in China ; Kamschatka ; Australia (Ballarat) ; the islands 
of the ^Egean, both Turkish and Greek ; Crete, and Cephalonia, 
and Malta ; Greece ; south-eastern provinces of European Russia, 
from the Crimea to the Sea of Azoff, and by the Caucasus away 
to Astrachan ; and in the Baltic provinces, Esthonia, Finland, 
and Courland ; in Sweden, Norway, Iceland, the coasts of North 
Italy and south-east of France ; the shores of the Mediterranean ; 
on the French coast, Provence, Languedoc, and Roussillon ; the 
delta of the Rhone, especially about Martignes and Vitrolles, and 
near Toulon and Marseilles ; in Spain more than any other Euro- 
pean country, especially Granada and Catalonia; in Portugal 
about the provinces of Lower Beira and the Algarve. It is en- 
demic at Madeira, and prevails in Mexico, Brazil, and West 
India Islands, New Granada, Venezuela, and Ecuador ; in 
Brazil it is common, and La Plata States ; in the West Indies, 
Cuba, Jamaica, Barbadoes, Guadaloupe, and St. Bartholomew 
chiefly ; and in North America, at New Brunswick. 

Its characteristic cutaneous feature is the development of a neo- 
plasma resembling the granulation tissue of lupus or syphilis, which 
invades the fibrous structures and the nerves. The production of 
this tissue is the result of some alteration of the general nutrition. 
There are two chief forms of leprosy — the tubercular and the non- 
tubercular, or as it is some times called the anaesthetic variety. 
There is no line of demarcation between the two. They run the one 
into the other, and there respective characters are often intermixed. 

In both varieties after a period of general ill-health or debility, 
not well marked in some cases, erythematous patches occur about 
the skin; these are succeeded by more or less deposit, and pre- 
sently anaesthesia develops. So that the three chief features are, 
as regards the surface, discoloration, deposit, ancesthesia. In the 
tubercular variety the deposit is the marked feature ; in the anaes- 
thetic variety the anaesthesia is the more marked — that is to say, 
the disease attacks in the latter the nerves by preference, and in 
it the results of nerve lesion are particularly perceptible. 

With these introductory remarks I will proceed to describe the 
two varieties of leprosy in detail. 

The ttibercular form (see figs. 33 and 34) commences with malaise 
— an indefinite feeling of something wrong — rheumatic pains — a 



312 LEPE0SY, OE ELEPHANTIASIS GE^ECOEUM. 

falling asleep of a limb frequently (generally referred, says Dr. 
Bowerbank, to some chill or sudden change of temperature), or 
with pricking sensations about the hands and feet. Sometimes 
these do not occur. In several cases I have seen (and which 
have been more than once mistaken in the early stage for 
syphilis) the patients have given some such history as this :' — That 
they have lived a long time in parts of India or elsewhere where 
the disease is endemic ; that they have had repeated attacks 
of " ague and fever," which have pulled them down very much ; 
and that some years afterwards brownish coppery stains began to 
appear in different parts of the body, and upon these small brownish 
tubercles formed, first of all about the nose and eyebrows, or ears 
or neck. The next thing noticed was a loss of sensibility about 
the little finger and corresponding side of the palm of the hand, 
with wasting of the muscles between the forefinger and thumb. 
At all events, very soon there is a dull red discoloration in 
patches : then the face begins to flush and swell, and looks over- 
heated ; then the limbs and trunk brown, and little tubercular 
formations make their appearance, first of all about the face, 
especially the ears and on the discoloured patches. From this 
moment the disease steadily progresses. The tubercles vary in 
size from that of a pea to that of a walnut ; they are soft, smooth, 
shining, of a dusky-red colour at first, becoming presently brown- 
ish-yellow, or bronzed. In the early stage, the sensibility of the 
part may be increased, in consequence of the pressure exerted by 
the blastematous effusion upon the nerves ; but after a while 
this morbid sensibility, if it existed, becomes altered in charac- 
ter, and, from the greater degree of morbid change, diminished 
sensation sets in, and increases until it becomes decided anes- 
thesia. On stripping a patient after the disease has lasted some 
time, one notices deep brown staining in patches varying in size 
from a shilling to the area of the hand over the front and back 
of the trunk, the arms, all round the neck (and of course all 
over the face) separated, save on the face, by healthy skin. Upon 
these patches are the tubercles in little parcels, or collected into 
one or more flattened elevated masses studded over the surface. 

The tubercles are most marked in situations where there is 
much lax cellular tissue ; therefore about the face, nose, lips, eyes, 
mouth, and ear. The disease may be more or less partial. The 
sebaceous glands now take on a hyper-action ; hence the skin is 
oily and shining. The increase in the development of the 
tubercles produces terrible deformity ; the surface feels thickened, 
knotty, or uneven ; the face is altered completely ; the edge of 
the mouth and lips, the eyebrows, the alee of the nose, the eyelids, 
are all distorted and thickened, the whole integument being dirty 
and sallow-like, and the various aspects presented by the patient 
have been described by the terms leonine, satyr-like, &c. The 
sebaceous glands become enlarged. When the lower limbs are 
affected, the disease is generally most marked about the lower 



LEPROSY, OE ELEPHANTIASIS GEJECOEUM. 313 

part of the thigh and ankle. Coincidently with these changes 
anaesthetic points appear in the centres of the oldest patches. In 
the cases I have seen, the parts supplied by the ulnar nerve were 
insensible, and this has only been discovered accidentally by 
burning or scalding, which has not been felt. The ulnar nerve 
can be felt enlarged and cordy above the elbow ; a good deal of 
pain of a neuralgic character occasionally accompanies the anaes- 
thesia. The muscles of the hand waste, the fingers cannot be 
apposed, nor the hand grasp properly or pick up small things, in 
consequence, even in an early stage of the disease. Not only the 
cutaneous but the mucous membranes participate in the same 
change. The mouth, the palate, the fauces, the trachea, the nose, 
the eye, are all affected by deposition of material in their mucous 
surfaces to a greater or lesser extent. The internal glands — e.g., 
the liver — indeed, all the internal organs, with the exception of 
the pancreas, are finally affected ; in fact, the system is generally 
implicated. The patient's general condition all this while has not 
been serious. He is morose, low-spirited, dull, and careless ; but 
now his troubles are commencing in earnest. His voice is altered 
or has been altered some time, being thick and husky ; he snuffles 
from the thickened state of the nasal mucous membrane ; his sense 
of smell, of taste, &c, are affected, and the time has come for ul- 
cerative action to set in in earnest ; the tumours soften, ulcerate, 
and pour out an unhealthy, offensive secretion, which crusts over 
the sore from where it comes ; the attempt at healing often fails. 
The eye is destroyed, the mucous surfaces of the internal parts 
ulcerate — e.g., the nose and its bones are destroyed. Diarrhoea 
from intestinal ulceration is often a complication : the bones 
become carious, hectic sets in, and the patient dies. Ulceration is 
not so common in India as in Europe. The duration of tuber- 
cular elephantiasis, according to Drs. Danielssen and Bock, is 
nine and a half years. But twenty or even more years is common 
in other climates. 

The following illustrations (figs. 33 and 34) portray the main 
characters of the tubercular leprosy. The one is a full-length 
portrait of an Eastern leper, with the tubercular deposits ulcera- 
ting ; the other shows the tubercular thickening of the structures 
of the face. 

The anaesthetic variety differs somewhat from the tubercular in 
external aspect. Whereas in the tubercular form the deposit shows 
itself in a very marked manner, and implicating the nerves only 
as it were secondarily, or at any rate not markedly at first com- 
paratively speaking, in the anaesthetic variety the disease affects 
primarily the nervous trunks, and very speedily leads to marked 
anaesthesia, and subsequent destructive changes ; and it may be 
readily conceived that the disease in its commencement shows 
itself more or less insidiously by symptoms indicative of some 
local nerve disorder. Not a little deposit may take place in the 
fibrous textures without disturbing the patient's health or coin- 



314 



LEPROSY, OR ELEPHANTIASIS GRJECORUM. 



Fig. 33. 




Fig. 34. 




fort, but a little nerve dis- 
order will soon show itself 
by anaesthesia and local- 
ized changes in the mus- 
cles. I think, perhaps, 
the fact of these local 
muscular affections occur- 
ring early in anaesthetic 
leprosy is not sufficiently 
recognized. This comes 
out in strong prominence 
in the accounts of leprosy 
recently published by the 
medical officers of ports in 
China, in the half-yearly 
reports of the Customs 
Gazette, issued from Pe- 
king. The general symp- 
toms of the ancesthctiG 
variety are the same as in 
the tubercular form. Lo- 
cally at the outset there 
may be many subjective 
sensations of heat, shoot- 
ing, burning, pricking 
sensations about the hands 
or feet, with more or 
less weakness, followed 
by tenderness, pain, and 
swelling along the course 
of the chief cutaneous 
nerves — e.g., the ulnar, the 
median, the saphenous, &c, 
ending in numbness and 
insensibility to irritants, 
and wasting of muscles. 
The integuments get 
parched, dry, shrivelled, 
perhaps covered by a clam- 
my sweat, and desquamate. 
Subsequently to this or 
coincidently, an eruption 
makes its appearance: it 
consists not only of ery- 
thematous patches, but es- 
pecially of bullae, which are 
of large size, occurring on 
parts previously ansesthe- 



LEPROSY, OE ELEPHANTIASIS GE^ECOEUM. 315 

tic — and as the nerve trunks are specially diseased, it is easy to 
understand why bullae occur — these break, and their place is sup- 
plied by superficial ulcerations, which, after scabbing, leave behind 
white, hard, hairless, and glandless patches of disease. Dr. 
"Vandyke Carter has specially studied this eruption, and I there- 
fore append his description, in which I agree, thus: — "Patches 
or spots of a circular or annular form, three-quarters to three 
inches or more in diameter ; edges raised, of a pinkish hue ; 
free from scales, slightly cracked or wrinkled ; centre depressed, 
pale, dry, glistening, having a tendency to spread and join so 
as to cover larger spaces." The central part of these patches 
is always anaesthetic, completely in cases of some duration, and 
feels hard to the touch. The patches may vary much by the 
presence of scales or slight desquamation, or slight ichorous exu- 
dation ; the hairs of the part are atrophied, and it is said not 
whitened (Carter) ; they are subsequently lost. The glands also 
suffer in like manner. This typical form of eruption is the 
haras of the Arabs, the leuce of the Greeks. The result of 
careful inquiry seems to show that these patches are the result 
of changes in the nervous supply, that they run the one into the 
other, and vary in aspect from simple white atrophied circles to 
large " isolated but blended patches," with or without red vas- 
cular margins, passing through the stages in which the centre is 
first red, then brown or pale, and surrounded by a distinct pink 
border of vessels. The centre of every patch gradually becomes 
more and more anaesthetic. The chief seats are the back of the 
hip, the front of the shoulder, about the elbows, and on the fore- 
part of the knee, over the temples, cheeks, trunks, and limbs. 
The eruption is symmetrical, and usually precedes the anaesthetic 
form. It existed alone in 14 of 186 cases (Carter), and in 48 of 186 
cases of anaesthetic leprosy. In a boy recently under my care 
from Bermuda the disease consists solely of these quasi-psoriatic 
brownish patches, with a slight scaly ridge bounding the areas, 
and with anaesthetic centres. 

Coincidently with the changes above described, the body gene- 
rally wastes, especially its muscular system: hence the fingers 
become distorted, and in a peculiar maimer : the first phalanx is 
bent backwards by the extensor ; the others are flexed ;- not only 
does this happen in the hand, but the feet and other joints also are 
distorted and rendered prominent. The bullae may give rise to 
deep, ragged, foul-edged ulceration, the base of which may be 
sensitive, proving the superficial character of the disease. The 
face is now much disfigured ; it looks haggard, shrivelled ; the 
skin is what is termed "mummified," or lax and loose. The 
mucous surfaces are exposed, in consequence of the " sclerotic " 
or hardened and contracted state of skin. The deeper parts now 
become affected ; a joint is seized with acute pain, a sinus forms, 
a piece of bone is discharged, and the sore heals. Dr. Cartel 



316 UNDEVELOPED FORMS OF LEPROSY. 

thinks this is an unusual mode (by necrosis) ; he believes that the 
deep parts are removed by " interstitial absorption," without pain 
or reactionary activity of any kind : the terminal phalanges are 
the iirst bones to suffer, and the disease, by steady progression, 
removes bone after bone. The mucous surfaces become involved ; 
they are infiltrated with " blastema," but not to the same extent 
as in the tubercular form : hence there is not so much diarrhoea 
or suppuration as in the latter disease; the patients live, on an 
average, about as long again — eighteen to twenty years. The 
ulcers of the surface are supposed to be due to irritants acting 
from without upon devitalized (anaesthetic) parts : hence they are 
seen in those accustomed to hard manual labour. In the latter 
stages, the general health suffers very materially, but not to the 
same degree as in the other form of leprosy. The patient dies 
worn-out by exhaustion, bodily and mental, or is cut off by some 
intercurrent disease. 

In certain cases leprosy partakes of the characters of both 
varieties, which only means that there are transitional stages 
between them. The mixed form of disease occurs in India in about 
15 per cent. It generally commences with eruption, which is 
usually of the white (the haras) variety: it also begins in one 
third of the cases under twenty and is rare after forty. The face 
exhibits the tubercles ; two-thirds of the subjects attacked are 
males ; and it is a fatal form, hereditary transmission being 
strongly marked. (Carter.) 

UNDEVELOPED FORMS OF LEPROSY. 

There are what I may venture to term abortive or undeveloped 
cases of leprosy, and I think, without doubt, there are many ano- 
malous cases of localized anaesthesia and muscular atrophy of limb, 
finger, and hand, especially when occurring in districts where 
leprosy is met with, which time w T ill show to be instances of 
aborted leprosy. A few cases of the kind have recently been 
brought before the Clinical Society of London, by Dr. Buzzard,* 
Dr. Anstie,f and others. Dr. Anstie's case I remember well, for 
he very kindly asked me to see the case in consultation with him. 

The transitional stages between mere impairment of sensibility in 
a part and real tubercular leprosy — taking as the intermediate stage 
anaesthetic leprosy with distinct eruption resembling psoriasis — are 
very well illustrated in a clinical Report on Leprosy, at Hankow, 
by Dr. George Shearer. J He remarks of his cases, that "some- 
times anaesthesia pure and simple has been observed to exist for 
a period of five years, but there is no case amongst them where 
the anaesthesia having lasted for a period of ten years, was not 
accompanied by wasting, paralysis, and ulceration. These, in 

* See Clin. Societies' Reports, vol. iii. f Clin. Soc. Trans., vol. iv. 

% Customs Gazette, No. x. , April — June, 1871 ; Shanghai, 1872. 



UNDEVELOPED FORMS OF LEPROSY. 317 

fact, constitute the connecting link with cases of true leprosy.'' 
He details some seventy-four cases of leprosy of different degrees 
and phases. The same facts come out in a Report on Leprosy by, 
I think, Dr. Manson, of Amoy, in a very striking way ; but at 
the moment I cannot lay my hand on the references. The paper 
contained an excellent clinical account of leprosy, and it will be 
found in the Customs Gazette. There are several diseases bearing 
local names that are in reality leprosy.* 

I have met with one or two cases in which the leprous taint 
seems to show itself by a modified eruption which runs an in- 
dolent course without any anaesthesia except in the patches, with- 
out actual deposit as in the tubercular form, and without any 
great impairment of the general health for a long time. For ex- 
ample, I had a case recently under my care in a lad from Deme- 
rara, who had large brownish patches on the face (both sides), and 
the arms, and extensive tracts of disease extending from the middle 
of the thigh to near the ankle, the boundary of the patches being 
slightly raised, dull brown, somewhat scafy, the general area dry, 
shrivelled-looking, dullish white, and feeling somewhat thinned : 
the sensibility being blunted over the whole of the diseased 
patches. The follicles of the skin appeared as if congested, and 
as though they had been the seat of deposit, which had been al- 
most entirely absorbed and had left behind a certain amount of 
atrophy. It was only when a pin was thrust deeply into the skin 
that the boy felt pain. There were one or two marked anaesthetic 
spots. There were little masses of deposit in the pharynx. The 
disease commenced by brown stainings, and appeared in the face 
nine months before. The boy had "fever and ague" in Demerara. 

* A disease called Ngerengere, occurring- amongst the New Zealanders, has been 
described by Dr. Thomson, and is clearly elephantiasis. Dr. Thomson's description 
is briefly as follows : — " It commenced with a cutaneous eruption on the extremi- 
ties, which extends over the trunk of the body. The eruption presents in some 
parts the oval patches and the copious exfoliation of a brown scaly morbid cuticle 
observed in lepra vulgaris (?) ; the irregular patches of psoriasis, and occasionally 
the innumerable fissures, the elongated and extensive cracks intersecting each other, 
of ichthyosis." There is frequently severe pruritus. The aspect of the disease is 
chronic, with a capricious course ; the hair is gradually lost from the eyebrows, 
eyelashes, whiskers, beard — not the head, axilla?, nor pubes, however. " The 
tattoo-marks are not affected." The mucous surfaces suffer, the voice alters, the 
eye becomes inflamed, the general surface livid; "the face, nose, lips, forehead, 
eyebrows, become swollen and shining ; but there are no tubercular deposits in 
them ; " the skin is not anaesthetic to any degree. In about a year the distal bones 
of the extremities (fingers and toes) are removed one by one by molecular or in- 
terstitial absorption : " a small boil or blister, or dry crack, appears in the direction 
of the flexures .... the soft parts ulcerate by a dry process ; the phalanx falls 
off, and the part heals." This is repeated year by year, the fingers generally being 
" dry, shining, and scabby-like." Death ends the scene before the wrist is reached, 
by diarrhoea, bronchitis, &c. The general health is not materially affected in the 
early stages. The disease attacks people under thirty years of age, generally after 
twenty ; and the great majority (five out of six) are males. It may attack several 
of the same family. The fingers are affected to a greater degree than the toes ; 
its duration ranges five or six years. From this outline we readily see that the 
disease is true leprosy. The Cacubay of Jamaica is probably leprosy. 



318 



PATHOLOGY OF LEPKOSY. 



First came brown stainings, then thickening, then a certain 
"paling and shrivelling" of the skin, with a dark scaly extending 
edge, and the blunting of the sensibility of the affected parts. 
The disease was not psoriasis. There was no hyperemia, no hyper- 
trophy of the papillary layer of the skin, no free scaliness. 
no affection of the elbows and knees. The disease was clearly 
" leprous." 

Morbid Anatomy and Pathology. — Elephantiasis is a disease 
which is chiefly characterized by the production and the infusion 
into the fibro-cellular tissues of a new granulation tissue. There 
is an important difference in the seat of deposit in the two varieties ; 

Fig. 35. 




(After Neumann. ) 
a. Is the epidermis and rete. b. Cutis with cell infiltration, c. Groups 
of colloid granules. c'. Colloid globules. d, Disorganized and dilated 
sebaceous glands with accumulated contents, e. Coiled hair follicle with 
atropic hair. /. g. Sinuous connective-tissue strains, formerly hair 
follicles (?). 

whereas in the tubercular form, the deposit — the new tissue — 
besides being more opaque, is deposited chiefly in the fibro-cellular 
structures, in the anaesthetic form it is more transparent, and is 
deposited, par excellence , in and outside the nerve tissue. In the 
tubercular form, the fibro-cellular coats and structures of all the 
organs except the pancreas are found infiltrated by the peculiar 
deposit ; in the anaesthetic, there is often an absence of this fea- 
ture in the internal viscera and their coats. 



PATHOLOGY OF LEPROSY. 



319 



Fig. 30. 



If a leprous papule be excised from the skin and examined mi- 
croscopically it will be seen that in tubercular leprosy the deposit 
of new tissue is seated chiefly in the corium ; it raises up the 
papillary layer, and extends to the subcutaneous connective 
tissue, surrounding the hair follicles and sebaceous glands, and 
more or less obliterating them after a while. There will be little of 
the normal tissue left when the deposit is excessive. The fore- 
going illustration (fig. 35), after Neumann, gives an excellent idea 
of the matter. This observer remarks that — " There is a continual 
production of small rounded cells, between which the intercellular 
substance becomes gradually more scanty, so that between the cells 
(arranged in groups and rows) are seen only narrow strands, of 
somewhat striped substance, the nuclei of which are rendered 
opaque by acetic acid." In fact the cell growths invade the fibrous 
textures gradually to more or less defacement of them. 

Yirchow has specially examined the leprous tissue, and remarks 
that in no case has he observed the 
transitional stages between spindle- 
shaped connective-tissue cells and 
simple granulation cells passing- 
through nuclear and cell division so 
perfect. The cells divide and sub- 
divide until a perfect form of ger- 
minal tissue is produced (see fig. 36). 

Dr. Vandyke Carter's and Daniels- 
sen and Bock's observations on 
anaesthetic leprosy still constitute 
about the only piece of information 
we possess as to the general morbid 
anatomj' of that variety of the disease. 
They may be briefly summed up here. 
He found the brain, spinal cord, and 
the roots of the nerves healthy. Dr. 
Fabre, who studied the disease in 
Brazil, noticed the brain to be 
atrophied, its ventricles to con- 
tain fluid, the glandulse Pacchioni 
numerous, and oftentimes a circumscribed suppuration in the 
membranes. Drs. Danielssen and Bock differ from Dr. Carter: 
they state that the spinal cord and its membranes are altered ; 
the latter being infiltrated with an albuminous deposit, a layer 
being found between the arachnoid and the pia mater ; the cord 
itself being indurated, its grey matter discoloured, yellowish, and 
devoid of vessels : the sheaths of the nerves and the various ganglia 
being similarly affected. They think the primary seat of the 
disease is the spinal cord. Dr. Carter, on the other hand, con- 
tends that the disease commences in the superficial nerves, and 
travels towards, but does not reach, the spinal cord. The sym- 




a. Lepra tissue ( after Virchow). Cells 
in division. 



320 PATHOLOGY OF LEFROSY. 

pathetic nerves are healthy; the heart, lungs, and intestinal canal 
healthy (Carter) ; the liver and kidneys fatty — in which all agree. 
The muscles generally are wasted and "fibrous," but not fatty, 
as a rule. The blood contains a more than ordinary quantum 
of albumen. The most important changes are observable in the 
nerves themselves. Dr. Carter sa} r s the nerve is swollen, dull red, 
or grey, or semi-translucent, rounded, and firm. The funiculus, not 
the connective coat, is the seat of disease ; the nerve is evidently 
very tense. The place of " the clusters of nerve-tubules" is 
supplied by the albumino-gelatinous infiltration which has pressed 
upon them ; the deposit surrounds the nerve-tubules, " mapping 
out, as it were, the area into polygonal or rounded spaces, in each 
of which lie the remains of one or two altered nerve-tubules." 
Hence the chief features are firmness, opacity, and enlargement, 
from foreign deposition. This is chiefly marked in the compound 
trunks which are situate most superficially, and in the " cutaneous 
nerves just after perforating the deep fascia :" those chiefly diseased 
are the ulnar, radial, and musculo-cutaneous ; and they may 
exhibit these changes over the space of an inch or more ; some- 
times, indeed, a greater distance along the parent trunk towards 
the spinal canal. The bones are " rarefied " by " molecular de- 
struction." As to the origin of the nerve disease, " it appears that, 
first of all, a clear material, probably albuminous, is deposited 
between the nerve-tubules, and in this nuclei, and subsequently 
fibres are developed, whilst the deposit itself may become fibrillated. 
The nuclei are often large, -g-oVo? tgVct m - m length, and -g-oVo" in. 
in diameter, clear, round, and very numerous." 

The causes of elephantiasis are not well made out. According 
to Dr. Yandyke Carter, all castes are tainted by the disease, espe- 
cially those of primary aboriginal descent and the hill tribes. As 
regards social standing, the disease appears chiefly in the following 
classes : — Native Christians, Marathas, or low-caste Hindoos, 
Mussulmans and Parsees, vegetable-feeding Hindoos, &c. ; Euro- 
peans are generally exempt. There is some little difficulty in 
ascertaining the influence of sex. The seclusive life of the females 
in countries where the disease abounds may explain in some degree 
the fact of its being more frequently seen in males. " In some of 
the leper asylums of the West Indies the number of the two sexes 
is about the same." The general opinion, however, is that males 
are much more usually leprous than females. Of 543 deaths of 
lepers in Bombay during twelve years, 409 occurred in males, and 
yet of 906 leprous patients treated in St. George's Hospital at 
Bergen, Norway, from 1841-6, 461 were males, 445 females. 
Dr. "Carter states that the proportion of sexes amongst all lepers 
in the Bombay Presidency is 4*38 males to 1 female. The disease 
appears sooner in women than men. 

Age has some influence ; the haras generally appears before the 
age of twenty, the tubercular sooner perhaps than the anaesthetic 



ETIOLOGY OF LEPROSY. 321 

form, wlii cli generally commences before the age of thirty. Male 
lepers greatly predominate between thirty and forty, and np to 
sixty. Damp and humidity, uncleanly habits, filth, and poverty, 
are conditions favouring the occurrence of elephantiasis. The 
anaesthetic disease is most common in India. Of 186 cases 
(Carter), 67 were anaesthetic, 40 mixed, If tuberculous, 14 exhi- 
bited the " baras" only, and 48 were cases of anaesthesia compli- 
cated with baras. There is no reason to think that syphilis has 
any relation to elephantiasis. In 64 of the 90 reports of Indian 
medical officers on leprosy, this connexion is absolutely denied. 

The question of the essential and immediate cause of leprosy is 
no doubt a difficult one to determine. 

In a document" recently circulated nearly all over the world 
with a view to obtain special information on the subject, Dr. 
Farquhar and I observe that " in estimating the cause of leprosy 
we must be very careful to distinguish between its production and 
its propagation. This distinction is a vitally important one, for we 
may have leprosy merely propagated, and that extensively, in cer- 
tain districts and under conditions, whilst we attempt to seek for 
its origination in the action of some malarial poison, or some pecu- 
liarity in the food of the people, or something outside the indi- 
vidual, and are so led completely astray and to wrong inferences. 
We might, in discussing for example the explanation of the cause 
of leprosy in the fish-eating habit of the people of a certain 
locality, argue that this could not be the cause of the disease, 
because the habit was not observed in other districts where the 
prevalence of leprosy is common ; but then leprosy might really 
be accounted for in these places by importation, or by the inter- 
marriage of lepers or the leprous with the healthy. In fact, we 
might very erroneously come to reject a peculiarity of life or diet 
as an element in the causation among certain leprous communities, 
because it is not operative in other cases where the presence of 
the disease is really to be explained by hereditary transmission or 
importation. It seems to us in searching for the actual cause of 
leprosy, most important to determine in the first instance, in 
regard of any given place, whether the disease is only propagated 
or produced, and if partly propagated and partly produced, to 
what extent relatively." 

I may add a few words in detail on these points, and first as 
regards — 

A. Propagation of Leprosy. — The causes of propagation are 
mainly three : — 

1. Intermarriage of the leprous or with the leprous. 

2. Hereditary transmission. 

3. Inoculation and cohabitation. 

4. Vaccination (?) 

* Scheme for Obtaining a Better Knowledge of the Endemic Skin Diseases of 
India, drawn up by Dr. Tilbury Fox and Dr. Farquhar. India Office, 1872. (Official.) 
21 



322 ETIOLOGY OF LEPROSY. 

First. As to intermarriage little need bo said. It sufficiently 
accounts for the occurrence of a large number of cases of leprosy 
in the offspring of lepers, and the continuous intermarriage of 
people of the same caste in India, enforced rigidlj 7 by custom and 
superstition, tends greatly to the spread of leprosy hereditarily. 

Secondly. As regards hereditary influence, this is most marked 
in children who are begotten by lepers far advanced in the disease. 
Of 623 cases to which reference is made in the Leprosy Report of 
the College of Physicians, 287 were known to be hereditary, and 
it is no doubt probable that this is not a correct proportion, since 
leprous taints in families are as much as possible concealed. 

Thirdly. As to cohabitation and inoculation. Of course these 
are not such potent causes as intermarriage and hereditary ten- 
dency in spreading leprosy, but still it is probable that they may 
account for a certain number of cases. The Leprosy Report of 
the College of Physicians tells us that "the all but unanimous 
conviction of the most experienced observers in different parts of 
the world is quite opposed to the belief that leprosy is communi- 
cable by proximity or contact." In a general sense and under 
existing conditions the view here taken may be correct ; but there 
is by no means a slight body of facts which seem to indicate that 
the inoculation with matter from a leprous sore — and this may 
occur in cohabitation and constant contact and in vaccination (?) — 
may give rise to the disease. It is certain that at present there 
exist certain conventional impediments to the occurrence of conta- 
gion which, so to speak, has no fair chance of operation. It is 
scarcely right to conclude that leprosy is not contagious because 
it does not show this quality under present circumstances. In 
order that it may be concluded with certainty that the disease 
is not contagious, it would be necessary to remove all the impedi- 
ments which have been raised by tradition, popular prejudice, and 
legal enactments, and which have kept lepers practically in an iso- 
lated world of their own, and to secure the freest intermingling of 
lepers with the healthy of the community (which does not at pre- 
sent take place), and then to observe no increased spread of the 
disease, before it could fairly be said that leprosy cannot spread 
by contact. 

But there exist, however, certain indications, that leprosy is 
apparently spread by the free contact of the healthy with the 
leprous in districts in which its appearance and spread can only be 
explained apparently in this way, and where in some cases the diet 
and morale of the people has marvellously improved and leprosy is 
not endemic in the district. Dr. Davidson, in speaking of leprosy 
in Madagascar, remarks : " It certainly deserves notice, that while 
the laws of Madagascar excluded leprous persons from society, the 
disease was kept within bounds, but after that this law was per- 
mitted to fall into disuse, it has spread to an almost incredible 
degree. This is no doubt due in part to lepers being allowed to 



ETIOLOGY OF LEPROSY. 323 

marry without hindrance ; but the natives are also strongly im- 
pressed with the conviction that the disease is inoeulable." (Lep. 
Kep. p. 221.) Then I will refer to another very remarkable series 
of facts, which are contained in the appendix to the excellent 
pamphlet of Mr. Macnamara on leprosy, before referred to, and are 
contributed by Dr. Hillebrand, of Honolulu. The disease was 
thought to be unknown in the Sandwich Islands till 1859, and 
on close scrutiny cannot be traced further back than the year 1852, 
or at the earliest 1848. Dr. Hillebrand has been at Honolulu since 
1851. A recent census numbers the lepers at 250, or nearly 3J- 
per thousand of the natives, and he thinks this is below the ave- 
rage. The disease seems to have been brought by the Chinese in 
1848. Here, then, the influence of hereditary transmission is out 
of the question. The disease arises in a clean nation : is unnoticed 
at first, and spreads slowly. And in no case can we better study 
the question of contagion. It so happens that the hygienic state 
of the natives and colony has improved, and not deteriorated. 
Animal food is within the reach of all. Labour is in great demand 
and well paid for. The natives are clad now like Europeans ; for- 
merly scantily, if at all. The climate is, perhaps, the finest in the 
world. Taxation is light. Yet, notwithstanding, leprosy spreads, 
and has spread from and around known lepers as from centres of 
contagion. Dr. Hillebrand saw the first leper in 1853, about 
twenty miles from Honolulu ; in 1861 he had got very bad, and 
six other persons in his neighbourhood had become affected. The 
same thing was observed, in 1864, in another village, the tax- 
gatherer of which had been for years the only leper in the place. 
Dr. Hillebrand observes that " the natives are of a very social dis- 
position, much given to visiting each other, and hospitality 

is considered as a sacred duty by them About one-fourth 

avow contact with other lepers as a cause." Dr. Hillebrand gives 
the details of several very interesting cases. Candid and scientific 
inquirers cannot overlook the significance of such facts as these 
and the attacks of those who dress the sores of the leprous. Of 
course in such a case as that of Honolulu, where the disease is 
propagated apparently and not produced, it is no use looking for the 
de novo cause of leprosy. 

It has been said that leprosy may be communicated by vaccina- 
tion, but if so it must be infinitely rare and scarcely worthy of 
being taken into account. 

It appears then that in searching for the cause of leprosy, al- 
lowance must be made for a large amount of propagated disease, 
through intermarriage, hereditary transmission, and contact with 
the affected; for, in fact, disease propagated from individual to 
individual. Having first therefore, in regard to any particular 
district, determined the amount and prevalence of propagated 
disease, the observer is in a position to investigate the production 
de novo of the remaining mass of disease. 



324 ETIOLOGY OF LEPROSY. 

B. The production de novo of leprosy (the true cause). In re- 
gard to this matter observers are directing their attention parti- 
cularly to the influence of climate and diet. As regards climate it 
is to be observed that leprosy occurs in climates the most diverse. 
Still climate does seem to me if not to produce at least to greatly 
favour the development of leprosy, emphatically in those who 
have been depressed or whose health has been undermined 
by malarial poisoning. My experience is that those who become 
leprous have suffered from repeated attacks of " fever " in mala- 
rial districts. As regards diet, it has been the fashion to ascribe 
the origin of the disease to the consumption of fish, especially such 
as is stale or bad ; others again have looked upon the consumption 
of rancid oil, others that of bad cereals, as the cause of leprosy. 
Now as regards the influence of a fish diet, leprosy is very abun- 
dant in certain sea-coast districts and among fish-eating people. 
There is no question of this. In Egypt the natives feed* (as I have 
myself observed) on a beastly compound of semi-putrid fish, called 
" fasciah ; " in Norway again the consumption of fish is large, 
as also at the Cape and in parts of India, where, in the fish dis- 
tricts, the folk eat quantities of foul fish ; and Dr. Carter observes 
with regard to occupation, that many of the lepers " are fishermen, 
many ryots, all of whom lived more or less on rice and dried or 
salt fish ; " but in his more recent report (1872 — Leprosy in Bom- 
bay Presidency) he remarks that " there is no clear evidence that 
any special article of diet either excites or predisposes to le- 
prosy." There are many exceptional occurrences in places where 
leprosy is endemic, in disproof of the theory of the causation of 
leprosy by ichthyophagic habits. 

Dr. Richards, of Balasore,* has very recently stated that — 
" The inhabitants of Balasore, or Northern Orissa, are, as would 
be supposed, from the topographical features of the district, a fish- 
consuming community, and, like the Burmese (who prefer 
the stinking nga pee to fresh fish) they consume fish which is 
in a semi-putrid state. Of this fact one is constantly reminded 
when driving through the station by the stench that issues from 
the baskets of fish in transit to the markets in the interior. Under 
these circumstances, according to the fish theory of leprosy, we 
should expect to find the disease very prevalent here. Such, how- 
ever, is not the case, but on the contrary it is very uncommon. 
It is seldom that a leper can be seen at the bazaars, or indeed 
anywhere in the district, except now and again an up-country pil- 
grim, who, by the way, never eats fish. 

" In the district of Bancoorah, where fish is very scarce, leprosy 
prevails to a very great extent, more especially amongst the 
members of the lowest castes, who, from their circumstances, 
consume the smallest quantity of fish. Moreover, the disease 

* Indian Medical Gazette, May 1, 1872. 



ETIOLOGY OF LEPEOSY. 325 

is said to be on the increase, though the supply of fish is 
diminishing. 

" In England we find the converse of this — a diminution which 
amounts almost to a total disappearance of the disease synchro- 
nously with an increase of the fish supply. From the tenth to the 
sixteenth century, at a time when fish was comparatively scarce, 
leprosy was frightfully common ; but since that time, happily for 
us, instances of the disease are extremelvrare, though fish is more 
generally consumed than it was. Any deductions drawn from 
these facts would seem to imply the very reverse of the conclusions 
arrived at by Mr. Hutchinson." 

It is very advisable that we should have more facts on this 
point, and with reference to the influence of the large and constant 
consumption of oil of a rancid kind. 

Another peculiarity of diet which may have great influence on 
the genesis, of leprosy, is the absence of such vegetables as contain a 
large amount of potash. Mere poverty of diet will not suffice, as the 
case of Ireland very clearly shows, to produce leprosy; for in this 
country the Avretched state of the population has not produced 
leprosy : it may be in great measure on account of the abundant 
consumption of the potato. It is a curious fact, worthy of mention 
in this place, that leprosy has much diminished in Iceland since the 
introduction of the potato into that country. This statement I make 
on the authority of Dr. Hjaltelin, the chief physician of Iceland.* 

The use of grain grown on uncultivated land is a matter that 
demands every consideration. In England it is usual to hear the 
people of that great tract of country, India, spoken of as of one 
race ; but it would be perhaps more appropriate to speak of the 
various nationalities of Europe as one people, than to believe that 
the Bengalee near Calcutta, the Rajpoot of Oudh, and the Puthan 
of the Punjab were one people. As to climate and modes of 
living, these races are also very differently situated ; but there is 
much similarity in one respect in regard to their diet — that the 
use of grain grown on uncultivated land is very common with 
these different races. My friend Dr. Farquhar is inclined to 
think that the use of such grain may have much to do with the 
genesis of leprosy. The point is one of much interest, but 
requires careful elucidation. The reader will remember that 
pellagra, which has much analogy to leprosy, is unquestionably 
caused by the consumption of diseased maize, and analogically 
speaking, this fact gives much countenance to Dr. Farquhar's 
view . The late Dr. Kinloch Kirkf supposed, as the result of his 
observations, that the use of leguminous seeds, commonly ranked 
in India under the name of dal, is capable of giving rise to some- 
thing like leprosy, and especially in the case of the dhal derived 

* Dobell ; Report on Progress of Medicine, 1869, p. 297. 
f Madras Quarterly Journal of Medical Sciences. 



326 TREATMENT OF LEPEOSY. 

from the cytisus cajan, and called "urhur." This is consumed 
by the poor under the idea that it enables them to bear great 
labour ; it gives rise as an occasional meal to general disturbance 
of health and rheumatic pains. Some eat it constantly, and the 
final results are urticaria, a sense of heat in the stomach, redness 
of the mucous surface of the mouth, bronzing of the skin, spon- 
giness of the gums, burning of the hands and feet, dryness, harsh- 
ness, and cracking of the same parts, rheumatic pains, white spots 
indicating a leprous taint about the body, and lastly, confirmed 
leprosy. Another dal, the lathyrus sativus, we know, induces 
paraplegia. How far the use of dal may be the cause of leprosy 
requires to be determined. But it must be recollected, after all, 
that leprosy may result not from the operation of any positive 
poison in climate or in diet, but negatively from the absence in 
the diet of certain principles, such as nitrogen and potash, and 
that it is accelerated by bad residence, uncleanliness, poor diet of 
all kinds, fever, and the like, and transmitted in the majority of 
cases hereditarily. 

These remarks, it is to be hoped, will suffice to indicate the 
direction in which we should attempt to make out the causa vera 
of leprosy. 

Treatment, — Until a recent date the leper has been looked upon 
as an outcast afflicted with an incurable malady and deserving no 
comfort and very little attention ; hence the treatment employed has 
been of the most unsatisfactory kind. The whole gist of the latter 
part of the Leprosy Report is to show the decided benefit to be 
derived from the adoption of means to improve the physical and 
moral condition of the leprous poor. " It seems indisputable that as 
the agricultural and horticultural condition of Britain advanced and 

the diet of the working classes was bettered leprosy 

became less common," &c. And in reference to India, the com- 
mittee observe that, "with its 150,000,000 of inhabitants, the 
question of the food of the people, in its probable relations to the 
wide-spread prevalence of leprosy and other endemic disorders, is 
a matter of the highest interest in an economical as well as in a 
scientific point of view. That a marked change in the habits of 
the native population will ensue upon the increase of divers in- 
dustries, the improved cultivation of the land, the less frequent 
recurrence of famines, and the consequent amelioration of their 
general condition from year to year ; and that better food, better 
clothing, and better housing, with greater personal cleanliness, 
will lead to the abatement of leprosy, may be confidently anti- 
cipated." — p. lxxv. 

The actual treatment in the past has consisted in preventing 
the intermarrying of actual lepers ; removing them from humid 
malarial localities ; altering and correcting bad modes of living in 
every particular; securing good exercise and a dry air; if possible, 
change of climate — all very excellent. In the actual disease, re- 



TREATMENT OF LEPKOSY. 327 

peated venesection, counter-irritation of the course of the nerves, 
various baths, arsenic, mercury, cantharides, &c, have been tried 
especially, but with no avail. Hydrocotyle Asiatica, Ginocardia 
odorata, or chaulmoogra (used by Dr. Mouat), the Asclepias 
gigantea or mudar, are looked upon as specifics ; lately Veronica 
quinquef olia has been praised : but all have failed and disappointed 
their advocates. The local treatment by arsenic was once recom- 
mended : an ointment, gr. x — xxx of arsenious acid to § j of lard 
being rubbed into a patch about six inches large, for a fortnight, 
so as to produce jpustulation. This is declared to have been often 
followed by great relief, the disease being treated bit by bit until 
it disappears — so it is said. 

There are two indications upon which the treatment of leprosy 
should be based. The first is, to check the increase of disease by 
improving the general health of the patients, and by placing them 
under the most favourable hygienic conditions possible. The 
second is, to promote the absorption of the leprous deposit. 
This is effected by the employment of both general and local 
measures. 

Now I believe that leprosy is to be ameliorated not in one but 
several ways. In some cases quinine in large and continued doses 
combined with occasional aperients will do very much good — at 
least this is my experience in England, and I think it does check 
the formation of granulation tissue. I have given gr. xx twice a 
day for some time, gradually getting up to this dose, and with great 
benefit. 

I do not like mercurials in the disease, though iodide of potassium 
and iron together are occasionally of service. I think it of con- 
sequence to use diuretics when the urine is scanty. I have no 
other remedy but quinine for leprosy, but I supplement it by 
iron, cod-liver oil, and other remedies to meet concomitant condi- 
tions. 

Locally the tubercles may be made to disperse by not one, but 
several local applications — ex.. carbolic acid as recommended by 
Dr. Fleming, in India.* This gentleman remarks that the 
application first hlackens the skin, instead of rendering it white, as 
is the case where healthy tissues are concerned. In some of his 
first cases Dr. Fleming " applied the carbolic acid in the proportion 
of 1 : 8, and occasionally some of the worst spots were touched 
with the pure acid. Latterly, it was found more convenient to 
employ it in a more dilute form 1:16 ( 3 j to § ij). The particular 
diluent employed does not seem of much consequence. The most 
generally useful is tilli oil, but any other bland oil would of course 
be equally applicable, and glycerine and water g produces a more 
elegant and very useful liniment." 

" In the more advanced cases of the disease, some care is required 

* Indian Medical Gazette, 1871. 



328 TREATMENT OF LEPROSY. 

in not pushing the application too far, as otherwise considerable 
excoriation of the cuticle is apt to take place, while, from the 
general insensibility of the surface, the patient is unable to give 
warning when this is likely to occur. However, on leaving off the 
application for a few clays, and anointing the parts with sweet oil 
or simple cerate, the lost cuticle is soon replaced, and but little in- 
convenience results." 

Arsenious acid has also been used with success.* The mode of its 
application is as follows : An ointment of from gr. x to gr. xxx to 1 j 
of lard is rubbed into the skin for a fortnight or so in different 
places, so as to produce pustulation ; on leaving off the remedy, the 
irritation and swelling subside, and the part treated gradually mends, 
with subsidence of the tubercles, it is said. Generally, a patch 
some 3 or 4 inches square is treated at onetime. I have no personal 
experience of this mode of treatment. 

The oil of cashew has been much lauded as a local remedy. Some 
cases do well under the action of cashew, others not so well — my 
experience, however, is not great at present as regards this remedy. 
The Beauperthuyand Bhau Daji treatments have been much lauded 
of late, but as far as the published evidence goes, they alleviate, not 
cure, as does the quinine plan of treatment I adopt. The Bhau 
Daji treatment is a secret, kept so by its prescriber. It is there- 
fore unworthy of scientific credit at present. The Beauperthuy 
treatment is given officially by Dr. Bakewell in a " Correspondence 
Relating to the Discovery of an Alleged Cure of Leprosy," published 
as a parliamentary paper in IS 71 : — 

" The patients selected for treatment should be in an early stage of the disease, 
that is to say, should not have been suffering from leprosy more than two years, 
and only those should be chosen in whom the disease is entirely confined to the 
skin, or has veiy slightly invaded the mouth. If the larynx has been attacked, 
and in other respects the patient is eligible, he should be distinctly informed, if 
treated at all, that it is only with a view to amelioration, and not to cure, that his 
case is undertaken. So far, no case has been absolutely cured in which the interior 
of the mouth or larynx had been invaded. The slighter the case the more easy 
and rapid is the cure. Both anassthetic and tuberculous cases are eligible. 

" The treatment is of three parts — 1st, hygienic; 2nd, external applications to 
the diseased parts ; 3rd, internal medicines. 

"The hygienic treatment, which is absolutely essential, and without which 
nothing but the most temporary improvement can be attained, consists of pure air ; 
nourishing food, including a moderate quantity of fresh meat daily ; abstinence 
from all salted meat or fish, and from pork, whether salt or fresh ; a sufficient 
quantity of fresh "vegetables must be given; and if the patients are habituated to 
its use, a moderate quantity of light wine may be given, but this is not necessary. 

" The external applications consist of (a) soap-and-water baths twice a day; 
frictions over the whole of the skin with oil. Cocoanut-oil is always used at Trini- 
dad and Cumana, but olive-oil might be employed if more convenient. The oil is 
well rubbed in and allowed to remain on for three or four hours, when the body is 
thoroughly cleansed by a soap-and-water bath. 

" The oil of cashew-nut is applied, by means of a small piece of sponge, to the 
diseased parts. This application should be made at first only over a small portion 
of the skin, as large, for instance, as the hand, and when the effect of the first ap- 

* See Dublin Medical Press, April 20, 1864. 



TREATMENT OF LEPEOST. 



329 



plication is seen, subsequent ones may be made larger if deemed advisable. The 
effect of the oil is to produce, after from twelve to twenty-four hours, vesication. 
The skin should, if possible, not be broken, and the exudation should be allowed 
to remain and dry on, so as to form a crust. In about ten or twelve days this will 
fall off, leaving the skin clear and free from any ulceration underneath. If the 
parts are numbed, but not completely anaesthetic, sensibility will in general be 
completely restored by the first application ; if the anaesthesia is complete, it may 
require two or three applications to restore it. 

• • After the first application or two, the patients will generally be anxious to 
have much larger surfaces operated on. I do not think it safe, however, to do 
more at one application than a leg or a forearm, or an equal surface elsewhere. 
The applications should not succeed each other at intervals of less than a Keek. 

''If the patients are troubled, as is very often the case, with herpetic or other 
eruptions, Dr. Beauperthuy employs two liniments with great success. The one 
called 

"Liniment No. 1 is made thus: — Saturate an ounce of alcohol with iodine. 
When the solution is complete add a solution of caustic soda to excess ; a little 
more or less is of no consequence, provided there is enough to unite with all the 
iodine ; then add twenty-four ounces of olive or cocoanut-oil. This must be well 
shaken up before it is used. 

" Li I anient No. *2. — Take the yolks of two eggs ; balsam of copaiba, four and a 
half fluid ounces ; mix to form an emulsion ; add one pint of olive or cocoanut-oil. 

'* May be employed in all those cases where there is a squamous or scurfy con- 
dition of the skin, in lieu of the oil baths. 

"Where the feet are affected, as it is not convenient to use the cashew-nut oil 
for them, baths of hot cocoanut-oil may be used night and morning. These must 
be superintended by a skilled attendant, who tests the heat with a thermometer, 
as the patient's sensibility will generally be deficient or null, and if trusted to him 
he might scald the feet without knowing it. The heat should not exceed 100° 
Fahr. 

' ' The internal medicines administered by Dr. Beauperthuy are perchloride of 
mercury (Ph. Br.), in doses of one-fifteenth to one-twentieth of a grain twice a day 
for adults. In cases where mercury is contra-indicated, Dr. Beauperthuy gives 
carbonate of soda, in doses of ten grains to a scruple twice a day. I have seen one 
case in which I tried the alkali, and which progressed quite as satisfactorily as 
those to whom the mercurial was given. 

• • It is of course to be understood that the treatment may be interrupted or 
modified, if any complications occur. Should the mercurial affect the mouth, or 
cause any irritation of the intestinal tract, it should be discontinued and the alkali 
given." 



Dr. Milroy tells me that as the result of his observations he has 
come to the conclusion that leprosy can be alleviated, but he attri- 
butes much of the success of Dr. Beauperthuy to the employment 
of hygienic measures in connexion with a liberal allowance of fresh 
meat. 



CHAPTEK XV. 

HYPERTROPHIC AND ATROPHIC AFFECTIONS. 

Under the terms hypertrophy and atrophy may be included all 
cases of development in excess of the normal tissues of the skin 
on the one hand and wasting on the other : the atrophy and hyper- 
trophy being in each case primary conditions. 

The maladies ranking under these two classes may be arranged 
as follows : — 

A. Hypertrophic diseases, comprising — 1. Diseases of the epi- 
thelial layer of the skin, including pityriasis, callosities, corns, 
and horns, in which the epithelial tissue is specially affected. 
2. Diseases involving the dermic portion, in which the true skin is 
affected with or without the epithelium. In some cases the 
papillary layer is chiefly affected, but in connexion with augmented 
production of the epithelium also, as in ichthyosis and xeroderma. 
In other cases the libro-cellular tissue of the corium proper is the 
special seat of change, as in the diseases termed scleroderma, 
keloid, fibroma, bucnemia tropica or elephantiasis Arabum, and 
dermatolysis. 3. Diseases seated in the vascular structures, 
including such growths as vascular naevi. 

Now it is just a question whether pityriasis is not essentially 
an hyperaemic condition, but I have ranked it as an epithelial 
hypertrophy. Keratoses is the term used by Ilebra and Kohn 
to include those diseases which are characterized by thickened con- 
ditions of the epidermic tissue of the skin — ex., warts, corns, 
horny tumours, ichthyosis. The class being subdivided into two 
groups, the one including those diseases in which the papillae are 
unaffected — ex., callosities, corns, horns ; the other in which the 
papillae are enlarged — ex., ichthyosis and warts ; but even this 
division is arbitrary, for in ichthyosis the tissues of the deeper 
part of the corium are often changed, and in callosities the 
papillae may be hypertrophied ; whilst in corns they may be 
atrophied. The primary mischief, however, begins in the epidermis 
in these two latter. I prefer my own subdivisions of hypertrophy 
above given. 

B. Atrophic diseases, including general wasting and senile atrophy, 
and local or linear atrophy, which will be incidentally noticed 
together with morphcea. 



HYPERTROPHIES OF THE EPITHELIUM. 331 

HYPERTROPHIC AFFECTIONS. 

1 will first deal in detail with hypertrophic affections. It will 
be understood that no reference is made in this chapter to secon- 
dary or accidental hypertrophy — the consequence of congestion 
or inflammatory conditions, but to those diseases in which hyper- 
trophy is the prominent or only condition. 

I. HYPERTROPHIES OF THE EPITHELIUM. 

I have been in doubt as to the position I should assign to pity- 
riasis, in which, as a rule, there is simply hyperformation of epi- 
thelial scales. I think it best to place it under the head of hyper- 
trophies for the present. 

Pityriasis. — This common form of disease may be discussed 
in a very few words. It is a primary form of disease — "a super- 
ficial cutaneous affection, sometimes accompanied by a slight rosy 
discoloration of the skin, or even a discoloration of another 
kind, but always exempt from those alterations of tissue which have 
been observed in the other elementary forms which we have 
described, and which scarcely presents any other characteristic 
phenomenon than a desquamation of the epidermis; this latter is 
detached in small whitish lamellae, or falls off in a fine, and, as it 
is called (from its analogy with wheaten flour bran— -furfur), fur- 
furaceous or branny powder." There is no exudation into the 
skin in ordinary pityriasis. The local symptoms are itching and 
heat. The redness varies much. 

Authors have made four main species — (1) P. versicolor, which 
is a parasitic disease, and will be found under the head of tinea 
versicolor. (2) P. rubra, which is primarily a hypergemia asso- 
ciated with disturbance of the trophic nerves, and has been de- 
scribed before (see p. 253). (3) P. simplex, to be now described ; 
and (4) P. nigra, which I do not know except as a parasitic disease, 
accompanied by pigmentary staining. The only variety I need 
notice here is P. simplex. 

Pityriasis simplex, according as it occurs in different situations, 
has received the appellations capitis, palpebrarum, pudendalis, 
oris, labialis, plantaris, pilaris (see p. 254). The history in all these 
cases is the same: a slight itching red patch appears, and then 
white scales form thereon, which are constantly detached : some- 
times a slightly red zone circumscribes the scaly spot ; the scales 
are continually shed and reproduced ; there are no other changes. 
The disease is met with on the bodies of delicate women and 
children, especially the head, where it constitutes one of the 
varieties of " dandriff." Pityriasis simplex is mostly a disease of 
early life. It is mostly confounded with seborrhoea ; in fact, 
seborrhcea contributes the great bulk of cases of " dandriff," and 
is often misnamed pityriasis capitis. 



332 HYPERTROPHIES OF THE EPITHELIUM. 

The Pathology and Cause. — The seat of the disease is no doubt 
the deep layers of the epidermis, and the nature of the disease an 
excess in the cell formation of the cuticle. This cell proliferation 
is an evidence of a somewhat lower type of vitality and implies 
nutritive debility. This may be the result of hereditary pecu- 
liarity, and it is certainly evoked by irritants of all kinds acting 
upon a debilitated system. 

Diagnosis. — Pityriasis may be confounded with (1) Seborrhea. 
The scales of the latter are, however, dull, white, and dirty ; they 
stick to the surface, and are made up of epithelial scales, with a 
large amount of fatty matter, whilst the sebaceous glands are 
often noticed to be distended in the disease. (2) Tinea circinata 
(parasitic) is always known by its circular character, its " frayed " 
aspect, its clearing in the centre and extension at the edge by 
quasi- vesiculation, and the presence of the parasite detectable by 
the microscope. (3) Pityriasis may imitate eczema, but it differs 
from eczema in the fact that there is no "discharge," and the 
scales are epithelial and not composed of inflammatory products. 
There is also little infiltration, no vesicles, pustules, and the like, 
and little pruritus. In all cases of scaly disease, I hold that a 
microscopic examination should be made in order to determine, 
the epithelial, or fatty (seborrhoea), or " blastematous " (eczema, 
herpes) nature of the scaliness. 

Treatment. — In the case of- pityriasis simplex local measures 
suffice. Where there are symptoms of local irritation — ex., red- 
ness and itching, an ointment made of two drachms of liquor 
plumbi and an ounce of lard will suffice. The principal object, as 
in so many other affections of the skin, is to soothe and slightly 
constringe. When the disease has become chronic, stimulating 
ajDplications may be used — the white precipitate ointment, the 
ung. hydr. nitrico-oxyd., or an ointment made of two drachms of 
ung. hydr. nitratis, to an ounce of lard, are serviceable. But when 
the disease is more extensive, and the scaliness free, it is necessary 
to give general tonics. In this case I use a liniment of equal 
parts of olive oil and lime-water freely, and subsequently nitric 
acid ointment (ttix — TT[xxto 1 j adeps), and commence with tonics — 
iron, quinine, nitro-hydrochloric acid, cod-liver oil, or arsenic, in 
case there be anaemia, dyspepsia, loss of flesh, nervous debility, 
&c. There must always be perfect cleanliness, thick greasy hair 
should be well and repeatedly washed. The food should be unsti- 
mulating, spirits and beer avoided if there be any " heating " with 
them. The bowels should be made to act regularly and freely. 
In chronic indolent cases, the following will be of use : — ammonio- 
chloride of mercury, and nitric oxide finely powdered, of each 
fifteen grains, olive-oil and adeps, each an ounce, with some scent 
to make the embrocation pleasant. Another form empirically 
successful is liq. ammon. fort. 3 ij, sp. rosmarini § ss, glycerinse f ss, 
aquae § viij, to be used twice a day, a little borax ointment being 



HORNS. 333 

used after each application of the lotion. The mineral waters of 
St. Grervais, Aix-la-Chapelle, Pyrenees, Bareges, and Luchon are 
recommended. 

Corns. — These are composed of an accumulation of the cells of the 
horny layer, which, generally, are pressed, together into a conical 
mass that dips deeply downwards. The papillse beneath may be 
enlarged, but are usually atrophied. The corn mass presses even 
upon the rete cells, and it also obliterates more or less the sweat 
glands. Corns are caused by pressure and friction ; they are of 
two kinds — the hard ordinary corns, and soft corns. The soft 
corns occur between the toes, and being saturated with the secre- 
tion of the part, are moist and soft ; generally there is some sero- 
sity effused under the upper layers or the bursae normally found at 
the parts over the joints of the toes where the corns form, enlarge 
and pour out fluid, which is discharged from a little central aper- 
ture. The treatment of these minor affections need not be detailed. 

Callosities are merely hardened conditions of the skin produced 
by pressure, differing from corns rather in the fact that they are 
on a larger scale than by any other feature. Those who visit Vienna 
hear a great deal about callosities, to which much attention is 
paid, as indicative according to their seats of various occupations, 
but all that I need say about them is that they are caused by pres- 
sure and friction. 

n. HTPERTEOPHY OF THE PAPILLA AND EPITHELIUM CONJOINED. 

Horns. — These may be sebaceous in origin ; usually, however, 
they are made up of hypertrophied papillse, each containing one or 
more vessels and being covered by epidermis ; on section they have 
a "granular texture pierced with small orifices, and when dry, 
numerous concentric cracks." These orifices are the sections 
of little blood-vessels ; " a' clear amber-coloured circular area sur- 
rounding each of the vessels, which are separated by the general 
granular structure of the mass, incapable in the compact part 
of the horn of being reduced to its ultimate original elements." 
The structure appears to be best seen at the edge of the horn, 
where "the vessels are seen occupying the axis of the papillae, 
which are indicated by the clear cylinder area surrounding the 
vessels, the limit of the clear cylinder appearing to be the basement 
membrane of the papillse, and presenting on an oblique section a 
somewhat jagged outline. The central parts of the horn are more 
compact and less vascular than the outside.'' (Edwards.) 

Verrttcje, or warts, are little raised tumours, sessile or peduncu- 
lated, hard, generally round, rugose, and mammillated. They are 
made up of coherent and enlarged papillae, each containing a loop 
of blood-vessels, and more or less nerve-tissue, especially at their 
base. I have seen them cover the face and present the appear- 
ance of disseminated lichen. In other cases they have been large 



334: XERODERMA AND ICHTHYOSIS. 

and in masses. The pedunculated warts and so-called acrochordon, 
are often the emptied sacs of sebaceous glandular enlargements — 
e. g., molluscum. The sessile warts, or the true hypertrophous 
papillae, are seen mostly on the hands in children ; they may be 
multiple, solitary, or aggregated in clusters. They may form a 
flat mass or present a digitate appearance. Y^arts are often the 
result of syphilis about the anus, vulva, penis, but they may also 
arise from simple irritation. Verruca necrogenica is the name given 
by Dr. Wilks to the warty growths which occur on the back of the 
finger-joints of those who are much engaged in making post- 
mortem examinations. " They are brown circular raised patches 
of morbid epithelium, giving the appearance somewhat of epithelial 
cancer," and curiously enough, if removed, they grow again ; they 
are caused by the acridity of the fluids of the dead body. I have 
seen one or two very curious examples of warts. On the little 
finger (at its outside) of a woman, for instance, a mass of warts 
packed closely together, and forming a patch If inches long and 
■J inch in breadth ; around the base it was hard, elevated, red- 
dened, something like lupus; it might be called verruca granulata. 
I have seen several cases in which the individual papillae of the 
skin, especially in the face, have become enlarged, their vascular 
part being involved, yet not sufficiently (in excess) to make the 
disease naevus ; it was a general equable hypertrophy of the 
structures composing the papillae. Condylomata are hypertrophied 
papillae moistened by secretion, and containing rather more fibrous 
and elastic tissue than usual. Formulae will be found for caustic 
nations elsewhere. 
The causes of warts are unknown ; they appear sometimes to be 
contagious. The treatment consists in destroying the abnormal 
growth by caustics — the acid nitrate of mercury, caustic potash, 
arsenical paste, perchloride of iron, or chromic acid. Dr. Bulke- 
ley recommends for the warts of children the application of a 
mixture of equal parts of dilute hydrochloric acid and muriated 
tincture of iron. 

XERODERMA AND ICHTHYOSIS. 

These two diseases are different forms of the same malady — the 
main features in each case consisting in the free formation and 
accumulation of epithelial scales, intermingled with more or less 
fatty matter, and forming branny scales or hard, horny, j)laty 
masses : in connexion with hypertrophy especially of the papillary 
layer of the skin, but the corium in some degree also: and in the 
deficiency of glandular secretion, whereby the skin is rendered 
harsh and dry. It has been usual to describe a true and false 
ichtlryosis according as the scaliness is made up of epithelial cells 
mainly, or associated with fatty matter in large amount. The 
distinction is less real than is generally supposed — the difference is 
one of degree, not in kind. 



applies 



ODERMA AND ICHTHYOSIS. 335 

Now ichthyosis is a primary form of disease ; it is not inflamma- 
tory, but often hereditary, and mostly congenital. A localized 
caking on the surface may result from sebaceous flux, and this will 
be described under the head of glandular diseases ; it is different 
from ichthyosis, a congenital disease associated with a generally 
disordered state of skin, which is not present in sebaceous flux. 
I will now proceed to describe xeroderma and ichthyosis in detail. 

Xeroderma (dry shin). — In this variety of disease the surface is 
peculiarly dry, harsh, ill-nourished, and wrinkled, instead of being 
soft, elastic, and smooth. It seems as if the skin had not been 
developed so as to keep pace with the growth of other parts. 
There is less subcutaneous fat than usual, and therefore the natural 
lines and furrows are mapped out more distinctly than usual. 
The skin looks dirty, the nails are ill-formed, whilst the surface is 
covered by thin cuticular scales or plates, free and loose at their 
circumference but attached in their centre. The aspect of the scali- 
ness varies somewhat : it is mostly f urf uraceous on the head, but 
is disposed in the form of plates on the face, and presents a farina- 
ceous aspect about the eyelids, the neck, and the trunk, where it 
maybe scaly. "When the scaly condition is well marked the variety 
is termed ichthyosis squamosa or simplex, but this is merely well- 
marked xeroderma, or rather I should say there is no line of de- 
marcation between the conditions termed xeroderma and ichthy- 
osis ; the difference is only one of degree as regards the epithelial 
collection. The skin is functionally disordered in xeroderma. 
The glands therefore do not secrete properly — the perspiratory, 
hence the dryness ; the sebaceous, hence the collection of altered 
sebaceous matter with the epithelial scales into large plates or 
horny masses. This form of disease may show itself immediately 
after birth, but its appearance may be delayed for one, two or 
several years after birth, and I think I have seen it develop ra- 
pidly after general eczema which has considerably disordered the 
circulation of the skin. 

Ichthyosis. — When the epithelial collections observed in xero- 
derma are exaggerated and marked, the term ichthyosis is applied 
to the disease. The scales in this form of disease vary in colour 
and thickness, and according to the aspect presented by them in 
these respects, varieties of ichthyosis have been made — the most 
exaggerated condition being termed ichthyosis cornea or hystrix, the 
least expressed form of disease ichthyosis squamosa, which is, indeed, 
only a well-marked xeroderma, as stated above. I have seen the 
characters of xeroderma well marked over large tracts of the body, 
and those of ichthyosis hystrix localized to particular regions of 
the same subject. 

The scales of old standing ichthyosis become discoloured and 
blackish, and this is seen in the squamous as well as the hystrix 
variety. 

In the slightest forms of disease, the features are those of 



336 XERODERMA AND ICHTHYOSIS. 

xeroderma well marked, and generally there are little areas where 
the collected epidermis mixed up with sebaceous matter is caked 
on to the part. 

When the latter feature is marked there are seen over the body 
in different parts, not scaliness, but a dark incrustation like dried 
black mud in aspect, and made of small polygonal masses which 
can be picked off. These masses stand one or two lines high. In 
the most exaggerated cases (hystrix) the whole of the limb, the leg 
or arm, is covered over by the same caked masses, the individual 
portions of which assume the aspect of spines, which may be very 
large. The affected part then has the aspect of the bark of a tree. 
The masses in all cases can be picked off, and the skin beneath looks 
dry and shrivelled ; in some cases the openings of the sebaceous 
follicles are seen to be somewhat dilated, and on the under surface 
of the detached plate are seen little plugs which have ritted into 
the ducts of the sebaceous follicles. In other cases, especially 
about the ankle, &c, the papillae of the skin may be considerably 
hypertrophied. Patients affected by any form of ichthyosis are 
somewhat thin perhaj)S, they are sometimes stunted in growth, 
they feel the cold weather terribly, and when this is severe or 
windy the skin becomes irritable, tender, and often cracks. The 
parts especially affected are the knees, elbows, and those about 
the ankles, the wrists, and the axillae. But the extent of surface 
over which the caking is marked varies ; it may be pretty general 
or local ; but however extensive it is, the skin generally is 
dry, harsh, mapped into small spaces, and scaly. 

After the above description the reader will readily comprehend 
that xeroderma and ichthyosis are degrees of one and the same 
thing, only in the former there is chiefly epithelial squamation 
and less fatty matter secreted ; in the latter the sebaceous secre- 
tion does not pass away insensibly as usual, but gets incorporated 
with the epithelial cells into plates, which are hard, dry, and dark- 
coloured, and vary very considerably in thickness. 

Ichthyosis is congenital, or at all events develops soon after birth. 
It is also hereditary, and affects the same sex throughout several 
generations. 

Ichthyosis of the Tongue. — Some writers have described an ich- 
thyosis of the tongue. Mr. Hulke* gives a case, which was charac- 
terized by yellowish- white, raised, tough, leathery patches, which 
are clinically distinguished from syphilitic or cancerous disease ; 
and there is a case/ 1 believe, described in "Holmes's System of 
Surgery." In May, 1872, Dr. Mercer Adams, of Boston, was good 
enough to send me a most interesting case, in which the whole 
middle of the tongue was covered by a dirty white, tough, hard 
growth, made up of epithelial matter pressed closely together in 

* Proceed. Med.-Chir. Soc, Feb. 28, 1865. 



XEKODEKMA AND ICHTHYOSIS. 337 

connexion with hypertrophous papillae. There was a central ridge 
a quarter of an inch high. The formation was very dense and very 
hard. It looked like moistened ivory. The man had had the 
disease many years, and was in general good health. The growth 
sometimes came away, and then re-formed. 

Dr. Church * has put on record a case of the kind, which oc- 
curred in a girl, aged fifteen, who was affected by the disease on 
one side of the body and about the tongue and palate. 

Now I am disposed to question the propriety of applying the 
term ichthyosis to the tongue. My reason is, that this so-called 
ichthyosis — which I would much prefer calling keratosis, or some- 
thing of that kind — is a purely local affair. It is not apparently 
congenital, and its general aspect is somewhat different from the 
discoloured skin of ichthyosis ; and lastly, there is no admixture of 
sebum with the epithelial matter. But I chiefly object on the 
ground of its local nature. Dr. Church's case is a very exceptional 
one — so exceptional (limited as it was to one side) that it is impos- 
sible to draw any general conclusions from it. 

Morbid Anatomy. — If a fairly marked ichthyotic patch be ex- 
amined minutely it will be found to be made up — proceeding from 
without inwards — of lamellae formed by flattened-out epidermic 
cells in great numbers. The cells are arranged in a striated 
manner, and these cells are seen to be undergoing fatty change in 
old cases of disease. The cells of the rete Malpighii, and 
especially those of the inter-papillary portions, are greatly aug- 
mented in amount ; in fact, the whole of the horny and mucous 
layers of the epidermis are sometimes enormously hypertrophied. 
But the papillae of the cutis are much altered : they are enlarged 
and elongated, their vessels are very much dilated ; and, in fact, 
it is around the elongated papillae as an axis that the epidermic 
cells arrange themselves in a concentric or stratified manner ; 
and, according to Rindfleisch, it is sometimes quite possible to 
get from off the diseased surface a shell, as it were, of epidermic 
scales, with a small central cavity which has been occupied by 
the elongated papilla. This disposition of cells and papillae ex- 
plains the breaking up from above downwards of the caking 
formed on the surface into separate and distinct small blocklets. 
The subjoined figure (fig. 37) represents the changes above de- 
scribed. 

But not only are the changes found in the papillary layer and 
the epidermis, but they are also met with in the corium. The 
bundles of its fibrous tissue are often thickened, and in well- 
marked cases of ichthyosis the hairs atrophy and the sebaceous 
glands are more or less obliterated. 

Diagnosis. — No mistake can well be made when the disease is 
fully developed. The congenital nature of the disease, with the 

* St. Bartholomew's Hospital Reports, 1863, p. 198. 



338 



XERODERMA AND ICHTHYOSIS. 



dry, harsh, non-perspiratory, scaly, ill-nourished state of the skin, 
showing the peculiar dark caking upon it, are diagnostic features. 
When the disease occurs, as it does occasionally, in a compara- 
tively localized form, it may be confounded with seborrhcea, the scales 
of which have become discoloured; but in the latter disease there 
is no papillary hypertrophy, the plates are thinnish, and cover over 
the dilated ducts of the sebaceous glands instead of the hypertro- 
phied papillae, and there is no evidence of concomitant mal-nutri- 
tion of the skin generally. 

Fig. 37. 




(After Kohn.) 

Section of ichthyotic skin. a. Accumulated epidermic layers, b. Rete 
Malpighii. c. Distended blood-vessel, d. Cells of cutis. e. Elongated 
papilla. 

Treatment. — The disease cannot be cured, but it can be relieved 
very greatly ; and, in fact, the patient can be made quite com- 
fortable with it. I have always been successful in getting patients 
into a continuously comfortable condition. In the first place I 
am careful to see that they are very cleanly, and that they are well 
fed and clothed. I then give cod-liver oil, and such remedies as 
quinine. I don't exhibit arsenic, because for the life of me I don't 
see the reason of giving it. Local remedies are the most impor- 



MORPHOEA. 339 

tank In xeroderma, any pain which systematically keeps the 
surface greased and slightly stimulated will benefit. It is imma- 
terial what grease is used— olive oil or elder-flower ointment is as 
good as any. In the horny forms of disease, a clear surface may 
be very readily obtained by careful soaking with glycerine, by 
poulticing or fomenting. The best plan is to use an alkaline bath, 
and, if the disease be too extensive, a warm alkaline (potash § ss to 
3 viij) lotion, to soften up the masses. After the scales are removed 
in the manner just indicated, the whole surface can be greased 
and an alkaline bath used twice a week, containing § ij to § vj of 
carbonate of soda and bran to the usual quantity of water, the 
surface being freely oiled after each bath. In this way the disease 
may be controlled so as to prevent it being not only a disfigure- 
ment but a discomfort, save that it requires occasional attention in 
winter, lest it become inflamed by cold. 

III. HYPERTROPHIC DISEASES OF THE CORIUM. 

Under this head are included all those diseases in which the 
fibrous tissue of the skin is in excess, and in which the disease 
extends to or involves the subjacent cellular tissue. These may 
be termed fibro-ceUular hyperplasias. They are (1) morphoea ; (2) 
scleroderma; (3) keloid; (4) fibroma; (5) bucnemia tropica; and 
(6) dermatolysis. Some writers group one or two of these diseases 
with new formations, but in truth they are rather characterized by 
alterations in the quantity and quality of the pre-existing fibro-cellu- 
lar elements of the skin than the formation of new kinds of tissue. 

MORPHCEA. 

Use and Relation of the term Morphwa. — Morphoea signifies form. 
It is in reality the same disease as that described by Dr. Addison 
as keloid — as, in fact, " Addison's keloid " — a disease wholly dif- 
ferent from the keloid of Alibert. It is most unfortunate that Dr. 
Addison should have employed the term keloid to describe it, and 
that certain writers should have continued to the present time to 
designate it as " Addison's " keloid. The term " keloid " is now 
appropriated by general consent to signify, in accordance with the 
original use to which it was put by Alibert, a fibrous outgrowth of 
the skin. As it is impossible, however, to apply the term mor- 
phoea to two diseases of a totally different kind, the innovation of 
Addison must certainly give way to the priority of Alibert. The 
term morphoea, therefore, as used by Mr. Erasmus Wilson, for the 
disease about to be described, is much the best. 

Morphoea occurs in connexion with as a phase of scleroderma, 
or may exist as the sole disease. It involves the whole thickness 
of the skin in all its parts. The disease occurs generally in non- 
elevated patches, varying in size from half-a-crown to several 
inches, which are originally red, but quickly become white, hard, 
dense, with a polished aspect, and an anaesthetic centre. The 



340 MOKPHCEA. 

patches are edged round with a network of vessels in the form of a 
lilac ring. The disease is not an outgrowth, not mere discolora- 
tion, but caused by a deposit in the skin of a substance like lard, 
which presses on and obliterates the vessels, hairs, glands, and 
nerves. When it is very white it is called morphoea alba ; some- 
times pigment is deposited, and then it is termed morphoea nigra. 
The whiteness is, however, generally very decided ; the patches 
look waxy, or like alabaster. Though there is no elevation of the 
skin as a rule, it is evidently thickened by the dense white deposit. 
The deposit is followed by considerable condensation. The epi- 
dermis is horny and sometimes yellowish, rarely desquamating. 
Once seen the disease is never forgotten. In some cases the 
deposit of material is not so marked as in others, but there is 
atrophy together with condensation ; still, however, the erythe- 
matous circle. This has been called morphoea atrophica. The skin 
is not polished, but white, dry, shrunken, parchment -like, anaes- 
thetic, and hairless, but this atrophied state may result secondarily 
from the absorption of pre-existing deposit of good amount, and 
then in some cases a certain amount of deformity may be produced 
about the face, where the deposit is extensive, the eye being drawn 
down perhaps. This might be termed scleriasis. 

Of twenty-five cases of morphoea collected by Wilson, " ten were 
atrophic, seven tuberous, five mixed, three melasmic;" eleven 
were unilateral, fourteen bilateral ; the trunk of the body was 
affected in eleven, the legs and thighs in seven, the arms in six, 
and the sub-mammary region in three. When morphoea occurs on 
the forehead it takes the course of the 'supra-orbital nerve. In 
one case I saw separate grooves — the one in which I could lodge 
my little finger, the other a piece of ordinary stick pencil an inch 
long — were formed ; the edges of the spots were red, the centres 
sunk, white, dense, and insensible. 

In morphoea, as ordinarily seen, there may be only one patch 
or several. In a case recently under my observation the whole 
trunk was marked by large patches that look at a distance like 
large wheals with their centres white and circumferences red, but 
these patches felt firm and were constant, and not itchy, so that 
their true nature was at once seen on careful inspection. The 
disease began by slightly red spots, the centre of which presently 
levelled down a little below the ordinary surface, then became 
white from the presence of the commencing deposit, the lilac ring 

fradually widening out in all directions, as the latter augments, 
'he seats of the patches of morphoea are, in order of frequency : 
the back of the neck, the upper part of the chest, the mammary 
region, the abdomen, the upper part of the thigh and the arm, the 
forehead, and the cheeks. Morphoea is mostly unilateral ; it occurs 
in females especially, and such as are of weak constitution; and, it 
is said, oftentimes in pregnant women. It is very chronic, and 
disappears slowly, after having lasted, it may be, a good many 



M0RPHCEA. 341 

years. I have seen it associated with changes in the raucous 
membrane of the inside of the lips, of the same character as that 
in the skin, the surface being white, shining, feeling indurated, 
and looking as if infiltrated with bacony fat. 

Relation to Scleroderma. — It is important to observe that in 
England the morphoea is observed as the early stage of scleroderma 
(which will be described next in order), not always, but not infre- 
quently. Some think that morphoea is in reality a circumscribed 
scleroderma, or scleriasis, as it is sometimes called. But as it 
occurs apparently as an independent affection, I have dealt with 
it separately. 

Nature of the Disease. — Morphosa is held to be a fibroid degene- 
ration, involving the whole thickness of the skin ; but more in- 
formation is needed on this point, and specimens taken from the 
affected would be especially interesting objects for microscopic 
studies. 

Diagnosis. — The following have to be distinguished from mor- 
phoea : (1) In the first place, leucoderma, which is merely white 
skin, resulting from deficiency of pigment in a particular spot or 
spots, without any textured- alteration whatever. If the colour only 
be attended to, and the deposit feature be overlooked, error is 
likely to occur. (2) Secondly, keloid ; but this is an actual out- 
growth of contractile fibro-cellular tissue, in which the elastic 
elements are unusually abundant; and (3) Thirdly, the early 
eruptive phase of leprosy, as seen in the anaesthetic form. In 
regard to this latter point, it may be observed that in leprosy 
certain anaesthetic patches with depressed centres, and it may be 
vascular edges, arising out of erythematous rednesses, or after 
bullae or brown discolorations, are present, as described so admi- 
rably by Dr. Vandyke Carter. These discoloured anaesthetic 
patches have been called morphoea, and the question arises whether 
these patches and true morphoea are one and the same in nature. 
It is probable that there is only similarity, not identity, between 
the two ; in each case there is a new deposit that destroys the 
skin and alters the pigmentation, atrophy following*; but in 
leprosy one does not see the white waxy deposit from the outset, 
and as the whole disease, but clearly a new deposit of different 
character, accompanied by evidence of general nutritive disorder, 
involving especially the nerve trunks. The morphoea I have been 
speaking of is a local affair entirely. 

The treatment consists in not irritating the local disease, and 
in adopting a general tonic plan of treatment, under which regime 
the disease will eventually get well or be arrested, but leave 
behind perhaps some atrophy. 

I have next to consider a disease w T hich is sometimes found in 
association with the morphoea just described, viz. : — 



342 SCLEKODEKMA. 



% SCLERODERMA. 

In the year 1854 Thirial first drew attention to this disease in 
a paper entitled Du Sclereme chez les adultes. The subsequent 
names given it have been scleroderma (Kretschmar, Schmidt's 
Jahrh.^ vol. cxxvi.) ; scleriasis ; hide-bound, disease ; scleroma, 
&c. Scleroderma seems to be the best, as it implies hardened 
skin, whereas scleriasis signifies rather the act or process of 
hardening. 

Typical Characters. — These are readily given. At first there is 
stiffness in a part whose movements are thereby somewhat inter- 
fered with — ex., in the nape of the neck, where the disease fre- 
quently begins. Hardness or horny induration in lines or bands 
then ensues, but there is no pitting of the part on pressure. 
But the stiffness and induration may come on suddenly over a 
large area, from groin to knee, for instance, or the whole front of 
the chest, and subsequently extend in bands or raised lines to a 
greater or less distance. The skin cannot be pinched up, and it 
is more or less immovable over the subjacent parts. The bands 
or plates of induration may run down the whole back or along 
the entire length of a thigh or an arm. The diseased surface is 
yellowish or waxy-looking, and the hue fades away in colour 
through a dull white into that of the surrounding healthy integu- 
ments. There may be a partial boundary line of vessels at the 
edge of the disease. The deposit or growth condenses and then 
contracts somewhat, the skin becoming dryer, denser, more parch- 
ment-like, whilst there is much deformity produced, especially 
about the face and joints, when these are the seats of the disease. 
Respiration may be hindered from the same cause, or the elbow 

Eermanently Hexed, or the eyes drawn down. Sensation is not at 
rst but only subsequently impaired. Several parts of the body 
are successively affected. Females are attacked more than males. 
There are sometimes one or more patches of morphoea present in 
addition, *>r the edges of the band or the indurated area may 
present the aspect of morphoea, being of a whitish hue, though 
raised. Scleroderma, when in bands or ridges, is distinctly raised. 
One writer remarks that " the appearance is not that of a tumour, 
but rather as if the arm had been burnt and had left a leather- 
like hardness, which required surgical operation as after a burn to 
remove it; or it seems as if a bad erysipelas had become turned 
into cartilage and bone." (Lancet , 1855.) The induration in this 
disease oftentimes after some time disappears. 

In newly-born children the disease sometimes occurs in the 
badly-nourished, and shows itself within the first few weeks and 
months of life, being preceded by a certain amount of hyper- 
emia perhaps, which is succeeded by the usual hardness and 
thickening. ' 



SCLERODERMA. 



34; 



It will be apparent to the reader that the so-called cases of 
morphoea of the face — which commences by white alabaster 
patches, gradually increasing in size so as to cover a large portion of 
the side, perhaps, and which by the contraction or atrophy of the 
deposit produces deformity — may be regarded really as cases of 
scleroderma, and, indeed, as forming a transitional stage between 
morphoea and scleroderma. This identity in nature is shown by 
the assumption, as 1 have above stated, by the edge of sclerodermic 
patches or bands, of the features of morphoea. It might be advisa- 
ble, perhaps, presently — if further evidence should bear out this 
relationship — to absorb morphoea into scleroderma, and to make 
two phases circumscribed and diffused scleroderma. 

Morbid Anatomy and Nature of Scleroderma,. — The disease is 
supposed to be " fibroid hypertrophy of the skin." Observers 

fenerally agree in regard to the minute appearance seen in care- 
ully prepared sections of sclerodermic skin. I have recently had 
an opportunity of fully investigating the changes in the diseased 
skin, and now proceed to state what they are. The general aspect of 
the skin is that of a tough, whitish, fibrous, and somewhat shining 
mass, studded over, it may be, here and there with minute yellowish 
points, probably masses of elastic tissue, but generally of a coarse 
fibrous appearance. The skin feels tough to the finger and offers 
much resistance to the knife, being in fact like a piece of toughish 
leather. On section the cuticle is found to be normal, except that 
there is more pigment than usual in the rete, and in certain 
cases the rete cells are increased in amount. In certain parts 
the papillary layer is not altered, but in others the papillae are 
flattened out and more or less indistinct. The distinction between 
corium and subjacent cellular tissue is lost, and the fibro-cellular 
structures of the corium and subjacent cellular tissue are greatly 
hypertrophied and condensed into a felt-like mass composed of 
thick bundles of fibrous tissue, with abundant elastic fibres inter- 
mingled and small collections of cell-oTOwths here and there. 
There does not appear to be much change in the capillaries or 
the nerves, as far as I can see. The fat is more or less atrophied. 
The hair follicles appeared in one case to be atrophied and 
more or less obliterated. I find the muscular fibres of the skin 
to be hypertrophied and the sweat glands particularly so, although 
the hair follicles seem to be atrophied. I find, in fact, that I am 
in complete accord with Xeumann on the subject." The changes 
above described are fairly represented in the subjoined figure (jtig. 
38), which represents the appearances presented in a section of 
sclerodermic skin which I recently examined. 

Recently Dr. Itasmussenf has written an admirable essay upon 
the subject, and in the post-mortem of one case affecting the chest 

* See Beitrag zur Kenntniss der Sklerodermie. Wiener Medizinische Presse, 1871. 
J See Edinburgh 3Iedical Journal, 1867. 



su 



SCLERODERMA. 



he found the epidermis thick, and beneath it a dense whitish fibrous 
substance, extending down in some places to the ribs ; the glan- 
dular tissue of the left breast and some of the intercostal muscles 
were replaced by fibrous tissue. The pleura costalis opposite the 
locality of the changed skin, the diaphragm, and the capsule of the 
liver, were indurated in little tubercular masses. On microscopic 
examination, the epidermis was found to be of the ordinary thick- 
ness, the papillae normal, the corium rather broader than normal, 
the connective tissue below much hypertrophied, and studded with 

Fie. 38. 




»wuu\\^£/^^^«^L--^/'T'a»te^^*NJ\\ 



The general fibrous structure of the section, made up of interlacing 
bundles of connective tissue, is well seen. At a is an atrophied hair 
follicle ; at b a sweat duct leading down to the coiled and enlarged sweat 
gland ; at c cell infiltration ; at d cut muscular fibres ; e elastic fibres, rep- 
resented also by the wavy dark lines running transversely over the field. 

spindle-shaped cells ; the small arteries were surrounded by closely 
aggregated cells, like lymph corpuscles — the peripheral oblong, the 
outermost spindle-shaped and separated by a homogeneous or 
slightly fibrillating membrane. Indeed, the vessels were en- 



RHINOSCLEROMA. 345 

sheathed in this lymphatic tissue. The hair duets and nerves ap- 
peared to-be unchanged. 

It is clear that the seat of the disease is the connective tissue 
and the corium. The disease, too, is an hyperplasia of the areolar 
tissue, invading the normal structures, and gradually obliterating 
them — ex., papillae, nerves, vessels, hair-sacs, &c. But some 
authors find the papillae more involved than others, and the elastic 
tissue more abundant. 

But what is the origin of the hyperplasia % Kasmussen thinks 
the disease commences by infiltration from the lymphatic vessels 
(lymphatic oedema of Virchow) into the connective tissue, the 
hardness being produced by the free development of cells in the 
fluid effused. This second stage, he thinks, is the only one gene- 
rally mentioned, the first, or erysipelatous inflammation of the 
lymphatics, being overlooked. 

Rasmussen declares that the changes in scleroderma are the same 
in kind as those seen in the bucnemia tropica, or elephantiasis 
arabum, and he thinks the seat of the disease is in the lymphatic 
system. The small arteries are surrounded by a sheath of lymphatic 
vessels, which furnish the lymph out of which cells are formed in 
the connective tissue at a very prodigious rate. He has accordingly 
proposed to call the disease elephantiasis sclerosa. 

The cause of scleroderma is not understood. 

The Diagnosis offers no difficulty ; the indurated, hard, tense, 
contractile bands are sufficiently distinct. 

Treatment is not promising. The opportunities of seeing sclero- 
derma are so few that no definite principle of treatment is laid 
down : the preparations of iodine with iron, cod-liver oil, nitric 
acid in large closes, change of air, chalybeate baths, and inunc- 
tion with black oxide of copper, gr. ij ad 33 (Rasmussen), are the 
remedies most usually employed. 

In regard to morphcea, tonics, especially the mineral acids and 
iron, by improving the health, help its removal, and as the general 
condition improves so does the local. 

RHINOSCLEEOMA.* 

Hebra has described in the Wiener Medizinisclie WochenscJirift, 
January, 1870, a peculiar new formation about the nose, which he 
has named Ehinoscleroma, and I quote his article in detail here 
because Neumann and others rank this disease with scleroderma. 
Hebra says : — 

" To form an idea of it, a substantial syphilitic sclerosis of the prepuce, in 
optima forma, may in imagination be transplanted to the external nasal structures, 
in one case even to the alae nasi, and in another to the nasal ridge ; to the mucous 
surfaces which form the borders of the nasal cavity ; or, lastly, to the skin of the 
parts surrounding 1 the nosel as the upper lip, skin, forehead. Among the nine 

* From the American Journal of Syphilography and Dermatology, April, 1870. 



346 RHESOSCLEROMA. 

observed cases there were only two which presented the disease on the nose, cheek, 
and forehead simultaneously ; in the others it was confined to the nose and upper 
lip alone. As a flat swelling, it projected as much as 1-^ lines in some places, its 
extent being always limited by a sharp border, with steep edges. The colour of 
this new formation varied from normal skin colour to a dark reddish brown. The 
upper surface of the diseased places was always smooth, rarely shining. The most 
striking objective symptom consisted in the extraordinarily complete induration of 
the affected places, which had an almost ivory-like feel. Besides this, the patients 
experienced but little pain, and usually only when the formation presented itself 
localized on the inner surfaces of the nose, and when these prominences were pressed. 
' ' In all cases the development progressed very slowly, requiring several years 
before the trouble had acquired dimensions which obliged the patient to seek 
medical aid." 

The following are characteristics, according to Ilebra, common 
to all forms of the disease : — 

"1. In their constant seat on the nose, and sometimes also in its immediate vicinity. 

"2. In the extraordinary induration of the affected parts. 

"3. In the exceedingly slow development of the pathological product, which 
appears either in the form of dark, brownish-red tubercles or knuckles, or as in- 
duration of the normal appearing tissue. 

" 4. In the sharp margination of these indurations, and the absence of all oedema 
or inflammatory symptoms in the vicinity. 

"5. In the absence of all apparent metamorphosis of the new formation, as it 
neither degenerates, ulcerates, softens, nor is absorbed. 

"6. In the failure of all internal treatment, even with the strongest agents. 

"7. In the absence of all danger to the system at large, even in case of its ex- 
istence for many years. 

" 8. Lastly, in the insensibility and painlessness, when the diseased parts are left 
untouched ; severe pain, on the contrary, when the dark red tubercles are pressed." 

Hebra adds : — 

" As the localization of the trouble in the face in eight out of the nine cases 
rendered it impracticable to remove even small particles of the new formation with 
scissors, we had to defer the microscopical examination until the acquisition of an 
appropriate case. 

" When, at length, such an one presented itself, the apex of the isolated tubercle 
was removed, and carefully examined by my assistant, Dr. Moritz Kohn ; he found 
the epidermis and the layer of the rete Malpighii of normal appearance. Between 
the elements of the latter especially there were no abnormal occurrences. 

' ' The papillae were somewhat longer than usual, conical or knobby ; their exter- 
nal connective-tissue structure markedly wasted ; the connective tissue of their 
body only present as a network of delicate fibres and small intervals ; their blood- 
vessels scarce and thin. The connective tissue of the vascular stratum also present 
only as a pale, thin, delicate network of fibres. This network of the vascular layer 
and of the papilla? was filled with small cells, crowded closely together, and the in- 
filtration of cells, at different places extended down deep into the corium, was, 
however, found regular, and close only in the vascular stratum and in the papilla?, 
which latter especially appeared stuffed with cells. The cells were smaller, espe- 
cially in the protoplasma, than the granulation-cells as a rule are, as we meet them 
in acutely or chronically inflamed tissues, and in places where the formation of new 
connective tissue is in progress. The nuclei of the cells were small, little refrac- 
tive, and finely granulated. 

" The cells appeared simply stored away in the delicate connective-tissue struc- 
ture of the papillae, and the upper layers of the corium, and by agitation were easily 
displaced. 

" The deeper layers of the corium showed a close connective-tissue arrangement, 
which had remained more free from the described formative element. The layer 
of fat-cells normal. Only spare cells in the fibres of the connective-tissue net here 
present, and there principally in the vicinity of the vessels. 

' ' Sebaceous and sudoriferous glands could not be found in the sections examined. 
The hair-bulbs, external and inner root-sheath of the hair, were free from all 
foreign formative elements, while the papilla? bordering on the hair follicle ap- 
peared crowded full of the above described cells. 



KELOID. 347 

" The above described sclerosis of the skin is, therefore, by this explanation, a 
cell-infiltration of the upper layers of the corium and the whole papillary body. 
The normal structure of the affected tissues has thus far suffered by the massively 
accumulated new formative elements, so that the connective -tissue structure of the 
papillae, and of the upper part of the corium, is forcibly separated and crowded out, 
and its elements are renewed. 

" The cells of the new formation nowhere exhibited that pale, dusted (finely granu- 
lated), indistinctly nucleated, not sharply contoured appearance (so-called degene- 
ration) of the cells in syphilis and lupus ; but they appeared well preserved, with 
sharp contour and distinct nucleus, and imbibed carmine well. 

'■ We believe, on the strength of the above microscopical characters, which cer- 
tainly made the clinical facts in the character and course of the new formation 
intelligible, though on'y imperfectly explainable, that this rhinoscleroma may 
be placed histologically next to the glio-sarcoma or granulation- sarcoma (Yirchow, 
Billroth). 

" In conclusion. I may be allowed to state something regarding treatment, 
hitherto of but little avail. In two cases, where the tubercles projected from the 
inner surfaces of the nostrils into the nasal cavity, and effectually prevented the 
ingress of air, I have destroyed the tubercles with caustic potassa in substance, and, 
after separation of the slough, have produced cicatrization by a frequent coating 
with concentrated solution of nitrate of silver (aa. p. aeq.). Compressed sponge 
introduced was effectual in ] re venting contraction of the cicatrix, and thus the 
perviousness of the nasal entrance, and the possibility of unimpeded ingress and 
egress of air, was maintained. It is of importance to observe that after destruction 
of the new formation with caustic potassa no regeneration took place, as this is 
observed in other format' ons, as for instance, epithelioma, and also that the 
neighbouring morbid product was neither disposed by the induced action to retro- 
grade metamorphosis nor to more rapid development." 

KELOID. 

This disease is another hypertrophic growth of the fibrous tissue 
of the surface. The characters of the disease are very well defined, 
and it is not very liable to be confounded with any other affections. 
It must be distinguished carefully from scleroderma and morphcea 
on the one hand, and fibroma on the other. So-called Addison's 
keloid is the morphoea before described. I am now dealing with 
Alibert's keloid — with keloid, in fact. 

It is usual to describe two forms, the true or idiopathic ; and the 
false or traumatic keloid, or the keloid of cicatrices. 

In true keloid, or kelis, as it is occasionally termed, but 
more properly idiopathic keloid, the seat of the disease is the 
corium itself, the morbid change consisting in hypertrophy of the 
white fibrous tissue of this part, forming a distinct, raised, well- 
defined tumour ; this tumour is at first pale, and then becomes 
pinkish and shiny, and oval in shape, and it presently sends out, as 
it were, offshoots of fibrous tissue like the claws of a crab into the 
surrounding parts, and these contract and produce distortion ; 
but the tumour or tumours if several (for there may be one or 
several), may remain in the form of flat, pale, or red, or sand- 
coloured elevations, the size of split peas or small nuts, for a long 
time. When the contraction sets in there are often much pain and 
itching, and when the disease is fully established it looks like an 
hypertrophous growth of the tissue of an ordinary scar, but seme 
what redder. If the growth be small it may look like a very un- 
ripe black grape. The term keloid y\ as given the disease from the 



343 



KELOID. 



resemblance of the circumferential outshoots or fibrous bands 
to the claws of a crab. The sensibility is blunted over the 
tumours, but there is no anaesthesia. There need be no pain in 
the tumour during its whole existence. Deformity is pro- 
duced by the contraction of the tissue of the keloid tumour. 
Kelis does not ulcerate, is unaccompanied by enlargement of the 
glands, and is not destructive to life. The general characters of idi- 
opathic keloid I have attempted to represent by light and shade, in 
fig. 39, which gives a very good idea of the disease, except its colour. 
The traumatic keloid, or keloid of cicatrices, springs up as an 
hypertrophic growth of cicatricial tissue, and follows the healing 

Fig. 39. 




A sketch after a cast in the Dermatological Collection at the College of 
Surgeons, showing in the centre the raised main fibrous outgrowth, with 
the claw-like processes at the edges. 

of wounds of all kinds, as after flogging, burns, boils, scars left by 
rupia, severe acne, the application of acid, syphilitic and scrofulous 
ulcerations, the piercing of ears for ear-rings (particularly in the 
negro), &c. The keloid of cicatrices usually begins as " very hard, 
small, shining, tubercular-looking elevations, of a roundish or 
oval shape, somewhat firmly set, of a dusky or deep red colour, and 
generally attended with itching and pricking, shooting or dragging 
pain in the part" which is the seat of a scar. These tubercles 
increase in size and grow pale, flatten out, and become depressed 
in their centre, which is marked by white traversing lines or bands, 
and a few straggling vessels. The increase takes place by means 
of offshooting claw-like processes, which run away from the edge of 
the tumour, and are from half a line to a line broad by 1J to 1 inch 



KELOID. 349 

long ; the growth is slow, and affects the whole area of the burn or 
scald, the site of which, in fact, becomes hard, leathery, and raised. 

Prof. Longmore, describing a case in which keloid occurred after 
flogging, says : " A small round tubercle appeared, which became a 
flat mass nearly as large as a man's hand, without pain ; there was 
some irritability, and it was tender where pressed upon by the 
cross-belt and the weight of the knapsack : on the front of the 
chest several small tumours, evidently of the same nature, were 
observed." The final result is admirably described in a case of 
keloid following a burn, under Mr. Curling's care, as follows : — 
" The whole seat of the burn has assumed a keloid state ; it is 
thick, bossy, indurated, looking remarkably as if very luxuriant 
and elevated granulations had healed over, and then, instead of 
shrinking, had undergone consolidation and some increase." As 
Mr. Wilson puts it, " false kelis appears to be the joint result of 
hypertrophy, condensation, and concentration of the white fibrous 
tissue of the skin, and by a special power of contraction would 
seem to draw the rest of the cicatrix to itself, and produce 
a puckering of the adjacent surface." In fact, the keloid of 
cicatrices is but the hvpertrophied fibrous tissue of the scar 
contracting freely, especially at the edge. 

Morbid Anatomy. — In keloid the disease consists in hypertrophy 
of the white fibrous tissue of corium with cell proliferation along 
the vessels. The growth is made up of closely-packed fibres with 
many nuclei, but few vessels. The fibres of the areolar tissue do 
not " constitute curly bundles, but thick trunks, the firmly com- 
pressed fibres of which run at first in an almost straight direction, 
gradually separate from one another, and finally fall into several 
distinct bundles, which, vibrating in curls, after repeated sub- 
divisions, are at last in nothing distinguishable from normal areolar 
tissue : " the trunks being closely compressed and interlacing, or, 
as Neumann remarks, the connective-tissue bands are deposited 
into wedges in the substance of the corium, and completely sup- 
plant it, as represented in the subjoined figure (fig. 40). 

The disease is supposed to begin by cell infiltration about the 
vessels of the corium, the change in the adventitia being marked 
especially at the edge of the growth, and at the part at which the 
arteries send offshoots into the papillae ; the cells are in the first 
instance spindled- shaped and collect by-and-by into distinct 
bundles of fibres. 

My friend, Dr. Duhring of Philadelphia, made a careful exami- 
nation of the tumour in a case of traumatic keloid and reported as 
follows : — 

" To the naked eye, upon section vertically through the tumour, the cut surface 
presented a structure close and compact in appearance, of a yellowish-white colour. 
To the touch it was tough, resisting-, and firm, with a certain amount of elasticity, 
and upon pressure exuded a thin, pale, straw-coloured liquid. After being prepared 
in solution of bichromate of potassa and alcohol, vertical sections were made and 
examined in glycerine. The homy layer of the epidermis was thin and scanty, the 



350 



KELOID. 



cells themselves being well broken tip, and many of them having- undergone granu- 
lar degeneration. The cells in the upper layer of the rete mucosum seemed closely 
packed together and unusually numerous, while the deep layer contained the pig- 
ment cells well coloured. 

" The mass of the tumour was composed principally of connective and elastic 
tissues, the former being disseminated throughout, while the latter appeared here 
and there in the form of good-sized, well-developed elastic bands, running both 
transversely and vertically. Fat was found in some parts in fine globules. Long, 
wavy bundles of connective tissue were seen running in strias transversely, just 
beneath the papillary layer. Here and there a cut sebaceous gland was found. 

" In some of the fields a loose network of connective and elastic tissue inter- 
mingJed was present, with globules of fat. Connective-tissue cells, long and 
twisted, were to be seen, sometimes approximating each other and again scattered." 

Fig. 40. 




3 





(After Neumann.) 
a. Epidermis, b. Rete Malpighii. c. Tissue of the cutis. 



of the cutis, e. Dense fibrous tissue of the keloid, 
around the adventitia. 



d. Remains 
/. Cell infiltration 



There does not appear to be any appreciable difference between 
the minute characters of idiopathic and traumatic keloid formations. 

Diagnosis. — The elevated tuberculous tumour, with the claw- 
like processes, the puckered state of the skin, the absence of ill- 
health, of glandular enlargement and ulceration, are diagnostic. 
The false keloid of cicatrices and true keloid, or kelis, only differ 
in the fact that one is idiopathic and the other secondary to cica- 
trization following lesions of the skin. Some observers have 
noticed yellowish points at the apices of the tubercles — a com- 
mencing fatty change. 

The ^Treatment of keloid consists in improving the general 
health, and preventing the irritation of the tumours. Locally, 



FIBROMA. 351 

the use of steady and continued pressure, iodine frictions, the 
passage of electric currents throught he tumour, and iodide of 
lead ointment has been recommended ; but I do not know of any 
better plan than the continuous application of contractile collo- 
dion to the tumours, to which the hypodermic solution of morphia 
may be likewise applied for the relief of pain. It is useless, it 
seems, to remove the tumour by caustics or the knife. Dnm- 
reicker however is said to have succeeded in removing a keloid of 
the lip by the application of an ointment made of acetate of 
lead 3 j, alum 3 ss, and an ounce of lard. 

FIBROMA. 

This is called by some writers fibroma molluscum or mollus- 
cum fibrosum. 

General Characters. — The disease in its usual form is charac- 
terized by the formation of outgrowths of fibrous tissue covered 
by integument of ordinary appearance, which outgrowths form 
distinct pendulous tumours ; the disease is, in fact, polypus of the 
skin. But I have observed a special form of fibroma, in which 
the disease consists of the same tumours, but of greater size, 
whilst the tumours grow very rapidly, ulcerate and become very 
vascular — in fact, after a while they take on a fungating cha- 
racter. I purpose therefore to make two forms {not varieties), 
fibroma simplex and fibroma fungoides. 

Fibroma Simplex. — In the early stage there is a softish tubercle, 
or there are several tubercles of the same colour and consistence 
as the natural skin ; it, or they, may be sessile, but soon get pedun- 
culated, and then gradually increase in size. They are flabby, 
generally more or less pedunculated. These tumours vary in size 
from that of a pea to that of a large fig and more. Sometimes 
the tumours are sessile. These fibromata are soft to the feel, and, 
as before observed, have the aspect of ordinary integument, but 
they are at times corrugated. The neck, chest, back, and more 
rarely the limbs, are the special seats of these tumours, which 
occur in elderly people usually. Mr. Wilson accurately describes 
the feel of these fibromata when he says that " taken between the 
fingers they often give the idea of a loose bag of integument, the 
looseness of the contained areolar tissue permitting of the inner 
walls being rolled the one upon the other." These tumours are 
now and then flattened from the pressure exerted by the clothes. 
There is no contractility about the growths as in keloid. The 
palms of the hands and the soles of the feet are almost always free 
from the disease. The accompanying representation (fig. 41) taken 
from a photograph sent me by my friend, Dr. Izett Anderson, of 
Jamaica, gives a good idea of the varying size of the tumours and 
the extensive way in which they may be sometimes distributed 
over the body. The little tumours look, in the illustration, like 
those of keloid, but they are to the feel soft, flaccid, and flabby, 



352 



FIBROMA. 



and unlike the hard dense tumours of keloid. I have had sketched 
a small solitary tumour (life size) separately in the illustration. 

Professor Ebert records the case of a man in whom there were 
107 tumours. I saw a case of Hebra's, at Vienna, in which the 
whole body was covered by them (of all sizes) ; one was nearly as 
large as a fist. The disease occurs in elderly people, and is not 
attended with any special danger. 

Fig. 41. 




Fibroma Fungoides. — Perhaps the best mode of illustrating this 
form of disease will be by relating the particulars of the last four 
cases which have come under my notice. This phase differs 
mainly from the other just described — viz., fibroma simplex (ordi- 
nary fibroma molluscum) — by the tendency to ulcerate, to rapid 
growth, and to vascularity. The tumours are, before ulceration, 
in aspect and feel like those of the simple variety, but when 
ulceration sets in, if in the young, they exhibit at the ulcerated 
part a pultaceous-looking surface, and in the old, as far as I have 
seen (in two cases), a livid red, apparently very vascular ulcerating 
surface, from whence issues a foetid ichor. In the first of my four 
cases there was a round raised tumour, as much as possible like a 
Normandy pippin in size and form and aspect, perhaps a little 



FIBEOMA. 



353 



redder, seated on the scalp of a gentleman. This tumour had 
slightly ulcerated. The second case was that of a patient sent me 
by Dr. Evan Jones, of Aberdare, who had over her body several 
huge sessile tumours, giving the aspect of normal integument at 
the base, but like masses of raw dried beefsteak over the upper 
area. The masses- were the seat of intolerable itching. There 
were smaller tumours, more like ordinary fibromatosis masses, about 
the body. On the breast there was one tumour as big as a large 
fist. It could be readily moved upon the adjacent parts, and 
rapidly ulcerated, exhibiting a foul, livid, red, fungating surface, 
which was specially offensive. 

Case 3 was that of a child in the Children's Hospital, w T hich Dr. 
West very kindly asked me to see. This was a remarkable case. 
The child was of young age, and was semi-idiotic. There were small 

Fig. 42. 




fibromatous masses about the ears, especially the concha, and a 
large tumour at the back of the head, just ulcerating, but save at 
the ulcerated spot having the look and feel of lax integument. 
The fingers (see fig. 42) were markedly club-shaped, and this was, 
produced by the development of fleshy masses resembling a half -ripe 
black grape seated at their tops on the palmar aspect, imbedded 
as it were in the fleshy end. This gave the child a very odd appear- 
ance, and I have attempted to represent its chief features as 
above. But this was not all : the whole of the tissue of the gums 
was enormously hvpertrophied, protruding about and around the 
23 



354 



FIBROMA. 



teeth so that they were imbedded in it. The disease began with 
the change in the gums, and one other child in the same family 
I saw with the same change commencing on the gums : a third 
being affected with the gum disease also. The fourth case was 
that of a woman of advanced age, under the care of Dr. Cockle, in 

Fig. 43. 




The arm is represented below with sessile tumours, having each a central 
punctum (the opening of the sebaceous gland ducts). 

the Koyal Free Hospital. She appeared to have been suffering 
from syphilis. There were syphilitic scars and tubercles about her 
skin, and about or from the seats of these tubercles arose lax 



FIBROMA. 355 

textured fibromatous masses. Those on the face, being large, 
luxuriant, and livid red, but of firmish consistence, stood out from 
the forehead, the nose, and the lips, as much as three-quarters of 
an inch in depth, causing overhanging eyebrows, enormously 
thickened alse nasi, and protuberant lips of great size. On the arm 
and legs were numbers of sessile iibromas of ordinary appearance, 
save that they were slightly purple in tint in parts, and some 
of them exhibited in the centre the openiug of a sebaceous duct. 
Some were the size of a big nut, and others half a walnut. The 
face and arm are represented in the foregoing illustration (fig. 43), 
which is only intended to give a general idea of the formations. 

In all these four cases the main characters were the same : the 
production of fibromatous masses made up evidently of fibro- 
cellular tissue growing rapidly, tending to ulcerate freely, and to 
become very vascular. The disease in the last case mentioned 
might with propriety be termed traumatic fibroma. The patient 
is getting well at the time of writing, under huge closes of iodide 
of potassium. The disease could not be termed keloid, for the 
characters of fibroma were fully developed. 

The Pathology of Fibroma. — The disease would seem clearly to 
be an hypertrophous growth of the fibro-cellular tissue of the skin, 
especially that part of it which constitutes the dermic layer of the 
hair follicle, and involving the sebaceous glands more or less. 
Dr. Beale settled this latter point as long ago as 1855 (Path. Soc. 
Trans., vol. vi. p. 313). The mass of the growths on section 
presents a surface with the aspect of fibrillating material enclosing 
collections of cells. Mr. Tlowse, of Guy's Hospital, has lately 
carefullv examined the tissue in a case of Dr. Face's, and states 
that "there is not any particular arrangement of this nucleated 
connective tissue, except that there and there it was disposed in 
bars across the preparation ; these bars were also occasionally 
seen in transverse sections as circles, looking something like 
gland tubes or vessels, from which, however, they were readily 
distinguished by their structure and the absence of any central 
canal." Dr. Beale concluded that neither the sebaceous glands — 
which may be involved and destroyed — nor the sweat glands 
were concerned in the formation of these tumours, but that the 
cells at the deepest part of the hair follicle and of the follicle 
itself were principally concerned ; and Mr. Howse confirms this, 
and locates the anatomical seat of the disease in the first instance 
in the two external layers of the dermic coat of the follicle. Dr. 
Fagge thinks that the sebaceous glands which are involved in the 
tumours are hypertrophied (see figure on next page, which repre- 
sents a solitary tumour, as in fig. 41, more highly magnified. The 
representation is from the Med.- Oh ir. Trans.). But neither Dr. Beale 
nor others allow this. Mr. Howse says, that in Mr. Fagge's case 
the glands were more sacculated than usual, and the acini more 
separated, but this was due to the growth of tissue between them, 



356 



FIBROMA. 



dividing them one from another. In the case of the child with the 
strange fingers, before referred to, Mr. Butlin, the excellent then 
Registrar of the Children's Hospital, examined the fibromatous 
tumour seated at the back of the head, which had the ordinary 
characters of fibroma, very carefully, and was good enough to 
give me the following description : — " General characters of the 
tumour : Not encapsuled. Bled freely on removal. It consisted 
of a tolerably firm jelly-like outer portion, and of a firmer opaque 

Fig. 44. 




white central portion. There was no appearance of division into 
lobes. A thin juice could be scraped away from the cut sur- 
face, but it was not abundant. This juice gave the ordinary 
characters of albumen when tested. Microscopic examination of 
section mounted in glycerine showed a more or less regular not- 
work traversing the section in all directions, the meshes of which 



FIBROMA. 



357 



were filled up by the coagulated albuminous juice. This network 
was composed, in the firmer portions of the tumour, of bands of 
well-marked fibrous tissue, often carrying vessels ; but in the softer 
portions of the tumour, merely of numbers of cell-forms, the exact 
shape of which was somewhat difficult to make out, but they ap- 
peared to be generally round or spindle-cells. Cells of various size, 
and generally round, large, and nucleated, were scattered through 
the basis substance. Whilst many parts, especially of the softer 
portion of the tumour, contained nests of cells and nuclei, which 
were often surrounded by a layer of fibrous tissue, and which re- 
minded one of the ducts of glands filled with cells and cut across." 
The figure 45 is a sketch which I made of one of these sections of 

Fig. 45. 




the tumour, the portion on the right hand is magnified, 150 di- 
ameters, and shows the nests of cells entangled in the fibrous 
stroma. The portion to the left is the central part of the represen- 
tation, more highly magnified to show the intimate relation of cells 
and fibres. The two large openings are the ducts referred to by 
Mr. Butlin. I imagine they are the sweat ducts cut across. In the 
former part of the tumour I found also very few cells, and only 
fibres with here and there a solitary cell or two. I imagine the tis- 
sue around the gland, represented in fig. 44, is the same in char- 
acter as that represented in fig. 45. 

Diseases resembling Fibroma. — There are instances of very lax 
pendulous outgrowths in which the integuments hang in loose 
^olds, and in which the fibro-cellular tissue is increased, which 



358 ELEPHANTIASIS ABABUM. 

resemble fibroma, except that the growth is not in distinct circum- 
scribed pedunculated tumours. Valentine Mott called this disease 
Pachydermatocele (see below). 

The Diagnosis must be made in the early stage from sebaceous 
cysts : in the case of cysts, the origin from a flat gland, the central 
aperture or entrance to it, and the fatty contents which can be 
squeezed out, determine the nature of the disease. The hard con- 
tractile sessile outgrowths of keloid could not well be mistaken 
for the lax, flabby, pedunculated tumours of fibroma, which have 
the aspect of normal integument. 

The Treatment is simple : when small, fibromata may be re- 
moved. In elderly men they are sometimes small, flat, and 
numerous — especially about the back, over the shoulders, and on 
the chest. I have never had the least trouble in getting rid of 
them all by the use of acid nitrate of mercury caustic to the 
smaller, and the joint use of that remedy and the ligature to the 
larger ones. 1 generally, after applying the acid, give an oxide of 
zinc paste to be used, to prevent too much irritation. 

There is yet another form of fibrous hypertrophy, in which 
greater laxity of tissue is observed. It is called — 

DERMATOLYSIS. 

In this affection the skin hangs in loose folds. Its fibro-cellular 
element is greatly increased. The affection really includes all pen- 
dulous conditions, from obesity, parturition, the state of skin in lax 
and enlarged mammas, and the like. Indeed it includes what 
Valentine Mott has called pachydermatocele. In the uncomplicated 
form of disease, the hypertrophic growth arranges itself in layers 
like the folds of a tippet ; there is little vascularity ; the sensibility 
of the part is diminished. Five chief seats of disease are men- 
tioned by Alibert, the eyebrows, the face, the neck, the abdomen, 
and the labia. Mr. Furneaux Jordan has described what appears 
to be the same disease, occurring in a collar-like mass around the 
ankle. I saw at the Orthopaedic Hospital, some few years since, 
under the care of Mr. Adams, an instance of this disease affecting 
the whole leg, and associated with pendulous folds, lax and soft, on 
different parts of the body. 

ELEPHANTIASIS ARABUM. 

Syn. Elephant leg, Bucnemia tropica, Barbadoes leg, Pachy- 
dermia ; called also by Erasmus Wilson — after Mason G-ood, and 
so named in the Museum of the College of Surgeons of England — 
Spargosis. 

Nomenclature. — There is a very unhappy confusion in the use 
of the term Elephantiasis at the present time. Most Indian 
officers, when they use the term "Elephantiasis," refer to the 
elephant leg, whereas in Europe, dermatologists signify thereby 



ELEPHANTIASIS AEABUM. 359 

true leprosy, or Elephantiasis Grsecorum, as distinguished from 
Elephantiasis Arabum, and the term is so used in the new nomen- 
clature of the Royal College of Physicians. I may ask our 
Indian brethren not to use the term " Elephantiasis " without 
qualification, but to append to it the additional term Arabum 
when the " elephant leg " is meant, and "Graecorum" when true 
leprosy is signified. Much confusion will be avoided hereby. The 
use of the term Bucnemia tropica, or " tropical big leg," and when 
the disease attacks the scrotum, "scrotal tumour," the sarcocele 
of the Egyptians, would banish all confusion, and is to be com- 
mended, so as to get rid of the word elephantiasis altogether. 
Leprosy being called leprosy. 

Description of the Disease. — The disease is to be found probably 
everywhere, but it is specially prevalent in Cochin China, the AVest 
Indies, Egypt, Barbacloes, Malabar, Abyssinia, Polynesia, South 
America, Japan, and Brazil. The disease usually attacks the 
lower limbs, and is mostly confined to one of them, but it may 
affect the scrotum, belly, breast, pudendum, and other parts. It 
is characterized by hypertixyphic growth of the cellular tissue of 
the skin, giving rise to general enlargement and alteration in the 
aspect of the skin, so that it becomes tawny, hard, dark, livid, 
thickened, often scaly, and perhaps fissured, whilst by-and-by 
warty points appear, so that the skin looks and feels like that of 
an elephant. 

The disease lasts a variable time, possibly a lifetime ; attacks 
all classes, and is non-contagious. The disease is marked therefore, 
when fully developed, by three features : — (1) Hypertrophic 
growth of the cellular tissue ; (2) alteration in the aspect of the 
skin ; (3) more or less deformity. And these changes are brought 
about as the result of intermitting and repeated attacks of inflam- 
mation of the lymphatics. In well-marked cases the disease is 
ushered in by distinct febrile symptoms, vomiting and head-ache 
at times, and it is said even delirium as a rarity : and locally, 
redness, pain, and tension over the course of the lymphatics, 
which presently feel knotty and corded — the glands being also 
swollen and tender. The constitutional symptoms soon vanish — 
in a few clays ; but the limb does not resume its natural size ; the 
glands es}:)ecially remain enlarged. A repetition of fever occurs 
at uncertain intervals, and after each attack the enlargement of 
the part affected is permanently greater ; and it has been ascer- 
tained, from careful observation, that the size of the affected part 
bears a direct relation to the frequency of the acute attacks of 
fever and local inflammation. The pain in the first febrile attack 
is severe, but it is slighter in subsequent ones. During the 
progress of the disease, deposit and thickening have been going 
on in the skin and subcutaneous tissue — hence the sensibility of 
the part is somewhat lowered ; but it is not as in the true elephan- 
tiasis, annihilated, nor indeed seriously lessened. • The swelling in 



360 ELEPHANTIASIS ARABUM. 

the disease may be pretty uniform or partial ; sometimes it is 
enormous, as when the disease attacks the scrotum ; then it has 
been known to produce a pendulous tumour of sixty pounds 
weight. The skin, as I have said, undergoes a peculiar change ; 
it is tawny, hard, dark, livid, thickened ; often scaly and fissured 
or greyish ; presenting warty projections, especially about the 
joints ; the veins are varicose, the surface then closely resembles 
the skin of an elephant. The subsequent changes are ulceration, 
with sprouting granulations (fungous), suppuration, and foul dis- 
charge. The glands participate in this action. Occasionally the 
lymphatics become very varicose, and dilated, and the surface is 
covered over with quasi-vesicles, some of which may reach the size 
of a pea, but these are seated in the substance of the cutis, and 
when punctured give out a clear or milkish fluid, which is lymph. 
This state of things is seen more particularly when the scrotum is 
affected. It is brought about by the dilatation and hypertrophy 
of the lymphatic vessels, and the vesicles observed over the surface 
are the dilated points of the lymph vessels. I had read somewhere 
of the scrotum being the seat of quasi-abscesses, I imagine brought 
about by an exaggeration of this state of things. 

The disease may carry off the patient by hectic. Frequently 
its progress becomes stationary, and the patient gets about as best 
he can with his unsightly deformity. The palms of the hands and 
the soles of the feet generally escape the disease. In this country 
a similar condition follows chronic ulcers of the leg; the limb 
enlarges, and its fibrous element hypertrophies so that it is nearly 
twice its usual size. The average size of 340 cases, round the 
ankle, Mr. Waring found to be 11 T 7 ¥ inches. Dr. Thebaud success- 
fully removed a scrotal tumour, which reached to within five inches 
of the ground ; it was 28 inches long, 20 inches in its bilateral 
diameter, its widest circumference 48 inches ; and it weighed 63J 
lbs. when removed, and the opening of the penis was 18 inches 
from the surface. 

The Pathology of the disease appears to be well made out. It is, 
as shown by actual observation, a hypertrophy of the derma and 
subcutaneous tissue, with the effusion of a blastema, of homo- 
geneous aspect, mixed up with a large number of molecules, 
granules, free nuclei, and nucleated cells. The first stage is in- 
flammation of the lymphatics ; as a consequence the lymphatics are 
obstructed, and fail to convey the lymph away, which remains 
behind in the tissues, and becomes coagulated and more or^ less 
appropriated in their hypertrophic increase. The epidermis is 
more or less affected — thickened ; but this varies in many cases. 
The cutis is thickened, the papillae are distinct and prominent, the 
subcutaneous cellular tissue (areolar, fatty, and elastic elements) 
is present in excess, and infiltrated by the lymph in excess just 
spoken of. The veins are distended, the lymphatics obliterated ; 
the muscles often pale and fatty. The internal organs also are 



ELEPHANTIASIS AEABUM. 361 

frequently in a state of fatty degeneration. The lymph, when first 
effused, is slightly milky, and contains albumen, some fibrine, &c. 
The primary seat of the disease is the lymphatics. A good paper 
on the morbid anatomy of the disease has been written by Dr. 
Vanlair.* This observer points out the purely hyperplastic cha- 
racter of the disease-, having carefully examined two limbs in a 
patient who died with the disease. Dr. Vanlair points out that the 
layers of the true skin hypertrophy, whilst the panniculns 
adiposus atrophies progressively, the hypertrophy of the epi- 
thelial tissues being secondary to that of the vascular tissues 
beneath them. He notices that the outset of disease is accom- 
panied by the appearance of lymphatic corpuscles in the cutaneous 
parenchyma without alteration of the proper tissues of the part. 
They are specially seen about the base of the papillae. 

Causes. — The disease is not hereditary ; it is not contagious. 
It attacks males more than females. According to Mr. Waring' s 
observations 75 per cent, of cases were males and 25 females. It 
is most frequent between the ages of twenty-five and fifty. Of 
945 cases collected by Mr. Waring, 729 occurred in people whose 
ages ranged between twenty-six and sixty ; 139 between five and 
twenty-five, and 77 after the age of sixty. In 5.65 per cent, true 
leprosy was found to be co-existent with the disease. 

The date of its first appearance is noted also : it existed since 
childhood in 16 cases; it appeared before the fifth year, in 7 cases ; 
between six and ten, in 33 cases ; between eleven and fifteen, in 111 
cases ; between sixteen and twenty, in 222 cases. As to the part 
affected, it was the right leg alone, or with other parts, in 307 cases, 
or 32 per cent. ; the leg alone or with other parts, in 287 cases, 
or 30 per cent. ; both limbs, &c, in 344 cases, or 36 per cent. ; in 
other parts alone, in seven cases ; in the upper limb in four cases. 
This agrees with Mr. Day's researches in Cochin China. He found 
that the disease attacked the lower limb in 93 per cent. In 224 
out of 226 cases, in which the point was examined, Mr. Waring 
found the febrile attack to be primary. Europeans are less liable 
than natives to be affected by the malady. Among the causes 
usually assigned for the disease are hot climate and malarial ema- 
nations, which occupy first rank. Mr. Waring thinks that the 
character of the water used by the inhabitants has much to do with 
the disease : " The sea- water, penetrating through the porous sand, 
renders the water saltish and brackish, and as the generality of 
these pools are surrounded by trees, it in addition soon becomes 
loaded with dead vegetable matter, which undergoing decomposi- 
tion, renders the water dark (almost black), and highly offensive to 
the taste and smell, which even boiling and filtering fail to deprive 
of its unwholesomeness." But indeed the cause is not made out. 

* Etude Anatomo-pathologique sur 1' Elephantiasis des Arabos : Bulletin de 
l'Acadeniie Royale de Medecine de Belgique ; Seance du 80 Sep., 1871. 



362 



AINHUM. 



Prognosis. — The disease is chronic. Mr. Waring found, in 218 
cases, the duration of the disease range between twenty-six and 
fifty-live years. If the disease is rapid, the febrile paroxysms 
severe and quickly recurrent, if there be much suppuration, and the 
general health be indifferent or bad, the prognosis is grave. 

Treatment. — In the acute state, venesection has been recom- 
mended. I should think quinine in full doses much better : but 
locally leeches to the lymphatic vessels, fomentations, rest, position, 
cold lotions may be used. In the chronic state, friction, pressure 
(continuous), bandaging, blistering ; and, internally, iodide of 
potassium, liquor potassa?, bromide of potassium ; and, as a last 
resort, ligature of the main artery running to the limb or tumour ;* 
pressure, and rest, are called for. Mr. Waring recommends 
quinine. Dr. Vanzetti has successfully employed compression of 
the arterial trunk supplying the affected part. Dr. Buchanan ex- 
plains the action of this procedure thus : — Tying the main artery 
does not reduce the size of a normal leg, but does that of an ele- 
phantiasis one, because the organs of absorption act differently 
upon normal and abnormal tissues. The activity of absorption, 
as a general rule, is in inverse ratio of that of circulation. When 
the force of circulation is weakened, the process of absorption is 
unusually energetic. This applies particularly to non-malignant 
deposits ; and absorption being once started, will often go on of itself. 
Thus, when a blister starts the absorption of an old effusion, that 
absorption will sometimes continue on unaided, and this is why in 
elephantiasis, after the operation, collateral circulation being soon 
established, absorption of the morbid material goes on. 

I have greatly relieved cases by the judicious combination of 
diuretics, rest, firm and continuous bandaging, together with 
mild mercurial friction to the limb. Continuous pressure by ban- 
dages or plaster-of -Paris casings diminish the size of the limb, 
especially in those cases which follow chronic eczema in England. 
Sometimes the limb ulcerates, and it may be a question whether 
amputation should not be performed. 

AINHUM. 

The name ■" Ainhum " signifies " to saw," and is the term ap- 
plied to a disease which is said to exist amongst the Africans ; Dr. 
Collas affirms that it occurs in India. The disease consists of spon- 
taneous amputation of the little toes, with hypertrophy of the am- 
putated part, as shown in the figures given, and for that reason I 
notice it here. 

* Cases illustrating the treatment of Elephantiasis Arabum by the ligature will 
be found recorded as follows : — Buchanan, British Medical Journal, 1867, p. 465 ; 
Vanzetti, Gaz. des Hop., No. 144, 1867, p. 572; Carnochan, American Journal 
Medical Sciences, July, 1867, p. 109; McCall Anderson, Journ. Cut. Med., July, 
1867, p. 180 ; Whitall, New York Medical Journal, May, 1867, p. 115. 



AESTIIUM. 



303 



A small semicircular furrow first appears in the digitoplantar 
fold, which gradually increases, without pain or inflammation, the 
toe enlarging to twice or thrice its size, and getting loose and in 
the way. If the toe is cut off, the wound left heals very speedily. 
The cause is unknown. The general health does not suffer. The 
disease is symmetrical. The amputated toe shows fatty change of 
the tissues, enlargement of the areolar spaces of some of the bones 
of the phalanges, the bone tissue between the middle and proximal 
phalanges being replaced by fibrous tissue, the separation of the 
toe taking place at the proximal, inter-phalangeal joint, and not the 
metatarsal phalangeal joint : the cartilage and articular end of the 



Fig. 46. 



Fig. 47. 





Fig. 48. 




Fig. 46 shows the feet with the appearance of appendages to the little 
toes ; copied from a woodcut in Dr. J. F. Silva Lima's paper in the Gazeta 
Medica di Bahia, for 1867, p. 149. 

Figs. 47 and 48 show the appearances presented on section of the appen- 
dage. 

Fig 47. a. Cicatrix of separation. 5. Joint between terminal and mid- 
dle phalanx, c. Remains of matrix of nail. d. Bursal cavity, e. Adipose 
tissue. /. Pigment of rete mucosum. 

Fig. 48. a. Ulcer left by amputation leading down to bone, d. b. Re- 
mains of matrix of nails, c. Ungual phalanx, joint structure unaltered. 
d. Middle phalanx, e. Adipose tissue of ball of toe unaltered. /. 
Thickened cutis and rete mucosum. 

middle phalanx being removed and replaced by fibrous tissue, 
which looks like an ordinary cicatrix. Information relative to this 
disease is greatly needed. 

IV. HYPERTROPHIC DISEASES OF THE VESSELS. 

This group includes those diseases of the skin which are called 
naevi, and also varicose veins. A nsevus is simply a hypertro- 
phied state of the vessels of the skin, occupying a greater or less 



3§k HYPERTROPHIC DISEASES OF VESSELS. 

extent of surface, from a pin-point to a whole region, or almost 
a limb. They may be congenital or acquired. When the venous 
tissue predominates they are called venous, and when the arterial 
capillaries are most concerned, arterial nsevi ; the colour is brighter 
in the latter case. In both classes the depth of surface affected 
varies. When it is superficial and slightly raised, and the venous 
radicles are affected, we have the port-wine mark or claret stain. 
Nsevi are oftentimes associated with pigment deposit in them, and 
may be covered with hair. Some undergo little change ; some 
steadily increase by the hypertrophy of old, or the development 
of new tissue ; the latter assume the aspect of what are called 
erectile tumours. ^/Microscopic examination shows that the coats, 
calibre, and radicles of the vessels are all hypertrophied and en- 
larged. Naevus araneus is the name given to a small nsevus of 
accidental origin in which there is a central prominent red spot — 
an aneurismal dilatation of an arterial loop — with veins radiating 
therefrom. 

Hypertrophy of the veins proper is frequently seen, and may be 
caused by obstruction to the onward flow of blood, or a natural 
want of tone in the vessels. It occurs about the nose very fre- 
quently, and in the veins of the leg as varicose veins. 

Under this head may be noticed another mixed form of tumour, 
to which the name of nsevoid lipoma is given. Mr. Erichsen has 
described it as follows: "It is a tumour in which the nsevoid struc- 
ture is conjoined with or deposited in a cellulo-adipose mass. This 
disease is invariably seated upon the nates, back, or thigh. It 
occurs as a smooth, doughy, indolent tumour, incompressible ; not 
varying in size or shape ; without thrill or pulsation of any kind, 
possibly having a few veins ramifying over its surface, but no dis- 
tinct vascular appearance. It is usually congenital, or has been 
noticed in early life." After removal, it is found to be composed 
" of a cellulo-adipose base, having a large number of veins rami- 
fying through it, so as to constitute a distinct vascular element 
communicating with small cysts containing a bloody fluid." 

Treatment. — If small, nsevi may be destroyed by caustic. If they 
show a tendency to enlarge, nitric acid should be applied to the 
extending edge, and the patch destroyed by degrees. In some 
instances excision is the most easy and rapid mode of cure. When 
the nsevus is extensive and venous, we may pass threads through 
various parts of the mass, leave them for twenty-four or forty- 
eight hours, till some slight irritation is set up ; then remove them, 
so that the growth may be obliterated by inflammation. Or we 
may inject perchloride of iron ; but the silk- thread treatment is 
much the best. In fact nitric acid, excision, and the use of silk 
sutures are the chief means of cure. So-called pigmentary nsevi 
are rightly described under the head of Maculae. 



ATROPHIA CUTIS. 365 



B. ATROPHIES OF THE SKIN". 

The conditions under which atrophy of the skin occurs are 
many and various. In the first place, atrophy of the skin may be 
more or less congenital, and is seen in connexion with xeroderma, 
for though the main features of this malady are an hypertrophous 
growth of the epithelium and the papillary layer of the skin, yet 
before these features become well marked, the skin generally is ill- 
nourished, and thinned in places, and after the accumulations of 
ichthyosis are removed, and the disease has apparently disappeared, 
the skin textures are sometimes thinned and wasted. Atrophy of 
the skin forms a part of senile decay ; it is also secondary to 
ulceration which occurs in connexion with the formation of new 
products in the skin, as in lupus and syphilitic disease of the skin ; 
or the degeneration of the normal tissues, as in morphoea : and it 
results from pressure on the arteries by tumours of different kinds : 
from nerve disorder, and so on. But I am only concerned here 
with atrophies which are primary, and such as constitute the sole 
disease present. 

There are two classes of primary atrophies — (1) atrophia cutis, 
and (2) senile decay. 

1. ATROPHIA CUTIS. 

The skin may be thinned and wasted in lines or in patches, the 
atrophy being the sole condition present. Every now and then a 
case comes before us in which the skin is atrophied in streaks half 
or an inch or two inches in length by two or three lines broad. 
This is the linear atrophy of authors. The skin of the atrophied 
part has a lower level than the adjacent parts, and it has a shrivelled 
and often a reticulated aspect. The cicatrices left in the abdominal 
wall after the distension of the abdomen, as in pregnancy, are of 
the same nature. This linear atrophy I have seen as an idiopathic 
condition, occurring about the legs, arms, and face, and consisting 
of two or three or many parallel lines of atrophy. It has likewise, 
as I have noticed, occurred after bad eczema or psoriasis in badly- 
nourished subjects. When atrophy occurs in patches, it is the 
result of some nerve lesion as far as I know. I have a case under 
my care in which the skin of the left half of the forehead and nose 
is thinned, blanched, shining, and more or less insensible, appa- 
rently as a consequence of an attack of zoster faciei, though the 
history of zoster is not satisfactorily clear. In the cases of true 
atrophy there is no antecedent deposit of new tissue as in mor- 
phoea, which I have already described, and in which the atrophy is 
secondary, but the atrophy appears as a primary phenomenon. 
Dr. Berkart has called my attention to a monograph by Dr. Louis 



366 SENILE DECAY OF THE SKIN. 

Lande* in which the subject of unilateral atrophy of the face is 
dealt with. Some interesting matter will be found in the mono- 
graph. Dr. Lande remarks that neither hereditary transmission, nor 
age, nor sex, nor temperament, seem to have any special influence. 
The disease has followed angina, measles, impetigo of the face, pains 
in the head — in solitary cases, but in other instances no precursory 
symptoms of moment have been present. In ten out of eleven times, 
the left side of the face was affected, the disease began with a peeling 
of the skin, folkwed by thinning and depression. The skin gives the 
same sensation to the hand as cicatricial tissue, the hairs turn white 
sometimes, the glandular secretions are diminished. The muscular 
irritability is not altered, nor is the sensibility much altered ap- 
parently. The lips may be atrophied, and the tongue and the palate 
are sometimes atrophied. The senses — taste, sight, and hearing — ap- 
pear to be unimpaired. Dr. Lande regards the affection as one essen- 
tially of the cellulo-adipose tissue, and independent of any affection 
of the trophic nerves — hence his term Va/plasie lainineuse progressive. 
The treatment of these cases of atrophy consists in the institu- 
tion of good hygienic measures, the regulation of the general 
health according to individual wants, and the judicious use of 
galvanism. 

2. SENILE DECAY OF THE SKIN. 

The best remarks on this matter are to be found in Neumann's 
work, and I shall content myself with a resume of the conclusions 
to which his observations have led him. The first great essential 
change which occurs in the skin of the aged is a diminution in its 
thickness and condensation. The loss of substance is particularly 
marked in the papillary layer ; so much so, that the outline of the 
papillae may be very indistinct, or the papillae may even disappear, 
the nerve-corpuscles and vascular loops alone indicating their 
former presence. 

The several parts of such an atrophied skin easily degenerate, 
hence several forms of retrograde metamorphosis are observed in 
it. Neumann specifies five : (1 and 2) Molecular or granular 
degeneration of two kinds, coarse and fine ; (3) colloid (Rokitansky), 
vitreous^ amyloid or hyaloid (O. Weber) degeneration ; (4) fatty 
degeneration ; and (5) pigmentary deposition. The granular 
changes are common, the three last of much rarer occurrence. 

In the granular degeneration, where the particles are fine and 
numerous, the fibres of the connective tissue are indistinct, and the 
texture of the cutis generally presents an albuminous appearance. 
When the particles are of the coarse variety, they are found chiefly 
in the upper layers of the cutis ; whilst the normal fibres of the 
cutis remain visible to some extent, which is not the case where 
the granular matter is of the finer variety. Neumann argues from 

* Essai sur l'Aplasie Lamineuse Progressive (Atropine du Tissu Connectif) : 
celle de la Face Particuliere (Trophoneurose de Romberg) , &c. Paris : Victor 
Masson and Co. 1870. 



SENILE DECAY OF THE SKIN. 367 

these facts that the granular material is the result of the breaking 
up or the contraction of the fibrillse, the finely-granular being the 
final stage of the degeneration. 

The vitreous degeneration is characterized by the entire altera- 
tion of the whole texture of the cutis into a substance resembling 
"solidified glue," nerve and vessel, gland and muscle being quite 
unrecognisable. The change commences, in the first place, in the 
walls of the small arteries, which are soon narrowed in calibre. 
This kind of atrophous change is common about the face and neck 
in persons beyond fifty. 

The pigmentary degeneration shows itself by the appearance of a 
great quantity of pigmentary granules in the rete cells and also in 
the outer root sheath, particularly its upper half, and in the form 
of diffused masses here and there in the upper part of the corium. 

These changes do not affect the epidermis, of course, for they 
take place in the cutis, but the epidermis is generally thinned, the 
rete cells being few and pigmented, whilst the horny layer is thin 
and its cells imperfectly hornified in places. In some cases warts 

Fig. 49. 






y 




MSI 



d 



(After Neumann. ) 

Section of sessile skin of forehead, showing shrunken hair follicles, some 

containing 1 epithelium, others sebum, and into whose base the enlarged 

sebaceous glands open, a. Granular cutis, b. Shrunken follicle with 

outer root sheath, c. Cells in follicle, d. Section of enlarged gland. 

like prominences are produced by the hypertrophous growth of 
the epidermic layer, but the cells if heaped together are immature. 
These changes are seen in fig. 49. 

Neumann further states that the blood-vessels of the skin are 
dilated and varicose, but not obliterated except in connexion with 
vitreous degeneration. 

The loss of hair from bald places in the aged is a characteristic 
feature, and I quite agree with Xeumann that the cause is to be 
sought, not in the obliteration of the vascular loops going to the 
hair papillae, but in the degeneration of the tissue of the hair- 
papillse, which being a portion of the cutis is involved in the 



368 



SENILE DECAY OF THE SKIN. 



changes by which it is generally affected. The hair follicles 
themselves only waste when the hair ceases to be formed, and 
Neumann states his inability to find any trace of the hair papilla; 
in bald (senile) places amongst the little mass of pigmented cells 
which are found at the bottom of the hair follicle. The material 
which is elaborated into hair is at first imperfectly and irregularly 
deposited. Then the hair formed is downy, the root sheaths are 
imperfectly developed, until presently no further attempt at hair 
formation is made, and the follicle finally shrinks from the fundus 
to the opening of the sebaceous glands, the inter-follicular fibrous 
wall of the follicle however remaining in the form of connective- 
tissue bundles, and the upper part of the follicle remaining as the 
duct of the sebaceous glands. 

The glands in the senile skin undergo much change : they are 
atrophied or entirely disappear in the parts which are normally 

Fig. 50. 



d- 




\v 



(After Neumann). 

Section of skin from a bald head. a. Hair follicle filled with horny 
cells, b. Downy hair. c. Greatly enlarged sebaceous gland, d. 
Arrectores pili. e. Muscular fibres. 

furnished with downy hairs, but in other regions supplied naturally 
with well-developed hair they seem to be invariably hypertro- 
phied, in the manner represented by Neumann in the accom- 
panying figure (fig. 50). 

The perspiratory glands do not appear to be much altered. 

The wrinkles of the skin are caused mainly by the loss of 
elasticity and contractility due to the atrophy of the tissues. 

The symptoms to which this senile decay of the skin gives rise 
will be described under the head of Pruritus Senilis. 

Atrophy of the hair, other than senile, as in alopecia, will be 
spoken of in treating of diseases of the hair. 



CHAPTEK XYI. 

NEW FORMATIONS, OR NEOPLASMATA. 
GENEEAL EEMAEKS. 

Neoplasmata are essentially characterized by the formation of 
new kinds of tissue in the skin. Neoplasms are observed in many 
different diseases of the skin, and under a variety of circumstances, 
but those diseases only are included in this chapter .in which a 
neoplasm forms the entire disease. The new tissue in neo- 
plasms has been regarded as originating in, and therefore an hy- 
pertrophy of, already existing elements ; but it is certainly not 
a pure hypertrophy, and it is new in regard to its characters and 
behaviour. On this account it is impossible to include the 
neoplasmata in any but a special group. The diseases which I shall 
describe in this chapter, as consisting solely in the presence of 
neoplasms in the skin, are lupus, cancer, and rodent ulcer. Now 
though in these diseases the local tissue changes constitute the 
primary, the essential, and at first, as before stated, the sole 
disease ; yet in the later stages of some, the general system may 
become deranged, whilst occasionally secondary growths are at the 
same time developed in various parts of the body. But these 
phenomena are entirely secondary ; in the former case they result 
as a consequence of the influence exerted by the local disease on 
the general health, and in the latter upon the infective quality of 
the primary mischief in the skin. 

LUPUS. 

This disease is characterized by an infiltration of the skin with 
a new cell growth, which is incapable of undergoing organization, 
and after a while is removed by interstitial absorption or by ulcera- 
tion. The neoplasm takes the form generally of tubercular eleva- 
tions, forming by their close aj;>proximation larger or smaller 
patches, which leave behind in process of cure indelible cicatrices. 

There are three forms of lupus, according to English writers. 
The first form, in which the deposit is slight and superficial, whilst 
there is no ulceration, is called lupus erythematodes ; it is different 
from the disease bearing the same name amongst German writers, 
and which has its seat in the sebaceous glands especially. The 
second form, in which the deposit is greater, giving rise to the 
tubercular formations, and in which there is little if any ulceration^ 
24 



370 OEDINAEY FOKMS OF LUPUS. 

is termed L. non-exedens. The third variety, L. exedens, is that 
in which ulceration occurs, and eats deeply into the tissues. 
Sometimes hypertrophy occurs together with cicatrization ; hence 
the unnecessary term lupus hypertrophicus. 

Now the truth is, that these forms of lupus are merely degrees 
of one and the same thing. If the neoplastic deposit is slight, 
and in the form of brownish-red spots or diffused non-nodular 
elevations, then the English call the disease lupus erythematodes. 
If the deposit or neoplasm forms distinct tubercular elevations, 
and does not ulcerate, the condition is termed tubercular or non- 
ulcerating, or lupus non-exedens ; and if the lupus ulcerates, it is 
designated lupus exedens, or exulcerans. The terms lupus vulgaris 
is now more generally employed to signify all the non -ulcerating 
phases of the malady. I venture to repeat the statement that the 
reader must not regard the lupus erythematodes of the English 
and the Germans as the same in character. But to prevent con- 
fusion, I shall first describe the characters, nature, and treat- 
ment of ordinary lupus, and then deal with L. erythematodes in a 
separate and subsequent section. 

A. ORDINARY FORMS OF LUPUS. 

Lupus Erythematodes of the English. — In its least severe or more 
superficial form — the erythematous variety of English writers — 
lupus consists of roundish patches of a deep red colour and shining 
aspect, without sensible elevation. The skin looks as though it 
had somewhat wasted, or become dry and shrunken from being 
"seared," being at the same time reddened. The morbid process 
creeps over the healthy skin (erythema eentrifugum of Biett), and 
the diseased surface becomes covered over with thin adherent 
scales, which on removal expose a dry yet raw-looking surface of 
gelatinous aspect, which is apt to bleed readily. Lupus might be 
described in its slightest form as like an obstinate erythema, with 
slight loss of substance. The central part of the well-marked disease 
often thins without ulceration ; the disease spreads from its boun- 
dary-edge, and its surface may exhibit some slight tendency to form 
crusts. The seats of this lupus are the face, the cheek, the nose, 
or even scalp ; general constitutional symptoms are absent, and so 
is local pain. The disease may ulcerate, and this occurs when the 
subjects attacked are scrofulous, which is not always the case, at 
least to the appreciation of the physician, or when the patient is 
cachectic. The disease mostly attacks children, and especially 
those of the lower orders. Of course individual cases vary slightly 
in aspect — from in fact an apparent erythema of dull red colour 
and great obstinacy, leaving behind a slight cicatrix, to, in other 
cases, a slightly indurated or elevated patch, in which the loss of 
substance subsequently is somewhat greater. Patches of this 
lupus may occur on the scalp, and on the fingers, hands, and toe?, 
resembling chilblains, but the patches are present throughout the 



ORDINARY FORMS OF LUPUS. 371 

summer, arid are accompanied by slight loss of substance, thus 
differing from chilblains. This last-named phase of lupus may 
co-exist with severer degrees of the disease. 

Lupus non-exedens, the term given to the next degree of severity 
of lupus, has as its basis the form first described ; but, in addition, 
little nodular elevations, which are softish, round, of a dull red, or 
reddish-yellow colour, often quasi-gelatinous-looking, stud the part, 
and by their aggregation or fusion form a patch of greater or less 
extent, and generally of circular or serpentine form. The tubercles 
are covered by little scales, presently quasi-scabs ; and little vessels 
are seen to run over and through the tubercles ; this is somewhat 
characteristic. This phase of lupus is seen in the face, especially 
about the nose, the lips, and chin. The central part of the patch 
may clear and cicatrize as the result of an absorptive process, 
without true ulceration, whilst the outer part remains tubercular. 
If the scales be removed from any portion of a lupus patch of 
the kind under notice, the part beneath is found to be red, dry, 
shining, or even raw ; the upper layer next the cuticle presents an 
appearance which has been termed " cornified," being of transparent 
glue aspect. The papillary layer of the skin is mostly affected in 
this disease. The process of healing is as in the other phase of 
lupus, always attended by more or less loss of substance and 
sensibility; the cicatrix is below the level of the adjacent surface. 
The loss of substance is rather by interstitial absorption than 
ulceration, as before observed. 

Lupus Exedens. — In this variety or form of lupus, ulceration is 
marked. The lupus commences in the usual maimer by the 
aggregation of tubercles, it then slightly discharges whilst crusting, 
and subsequent ulceration occurs. The tubercles in this variety 
are perhaps harder, and lack the transparency of those in L. non- 
exedens. The ulceration varies in depth, being in some cases 
comparatively superficial and extensive, or, on the other hand, deep 
and circumscribed. The peculiar destruction of tissue affects all 
the structures so that even the glands and hair-forming apparatus 
are destroyed. The disease may attack the vulva. 

Etiology of Lupus. — Lupus is a rare disease after thirty-five, and 
not common after thirty years of age. It may be seen in the earliest 
years of life. It is often regarded as an evidence of the strumous 
diathesis in the attacked, but I cannot subscribe to this view. 
Lupus, no doubt, often occurs in strumous subjects, but it may be 
present in those who have not a trace of struma about them. I 
am much more inclined to regard the disease as showing a predi- 
lection for the tuberculous subject; indeed, in many cases it occurs 
in phthisical subjects. The disease is more common in the country 
than in town, and rather more in the female than the male sex. 
Devergie found that twenty-five out of forty-seven cases were 
females, and Hutchinson forty-six out of seventy-four. Lupus 
is most common in persons whose ages are between fifteen 



372 ORDINARY FORMS OF LFPUS. 

and twenty-five; sixteen years was the average in Hutchinson's 
seventy-four cases. Its selective seat is the face. In forty-one of 
forty-four cases, according to Devergie, this was the case ; the 
nose was affected in sixteen cases ; the nose and other parts of the 
face together, in twenty-six cases ; the lips, four times, &c. Lupus 
is on the whole a disease of the poor rather than the rich. My 
own observations are confirmatory of the above statements. 

Pathology. — The material which constitutes the tubercles of 
lupus is a new formation. It is made up of small round cells 
resembling lymph corpuscles, and answering in the mass to the 
characters of granulation tissue, as described by Yirchow. It is 
to Auspitz, Neumann, and Bindneisch, that dermatology is chiefly 
indebted for a clearer insight into the morbid anatomy of lupus. 
In ordinary lupus the seat of the cell infiltration is the corium. 
My friend Dr. Auspitz,* found (see fig. 51) that in the early 
stage of tubercular (non-exedens) lupus the epidermis was arched 
forward, the Malpighian layer increased in extent, though it was 
not notably altered in structure. In the fully developed disease 
the corium is increased in thickness throughout. The papillae are 
more prominent, and the fibrous tissue elements are more abundant, 
on account of the presence of thicker fibrous bands and meshes 
than normal, which meshes are increased by additional fine fibres 
forming still narrower meshes. The whole corium thus increased 
from the papilla above to the subcutaneous tissue below, Auspitz 
finds to be uniformly loaded with a cell growth, the cells of which 
are oval, and have more or less distinctly nucleus ; the cells vary 
in diameter from -003 to .005 mm. The origin of these cells 
from the connective-tissue corpuscles, a view held by Yirchow, 
seems to be indicated by the presence of transitional forms between 
the two. The sebaceous glands appear to be obliterated. The 
sudoriparous glands remain unchanged. The hair follicles are in 
many places transformed into round alveoli, and constitute the 
yellowish-white tubercles so often seen shining through a patch of 
lupus. The subjoined illustration (fig. 51) is from Dr. Auspitz's 
essay, and portrays the above-mentioned changes. 

In the cases of lupus, in which the disease consists not so much 
of tubercles as in a superficial infiltration, Dr. Auspitz noticed 
that the rete Malpighii was increased to twice or three times its 
normal thickness, its cells having apparently undergone fatty 
change. The papillae were filled with the lupus cells, which were 
especially abundant along the capillary vessels therein, the vessels 
themselves being dilated and coiled to a marked extent, and 
surrounded by an increased amount of connective tissue. 

When lupus cicatrizes, the " lupus scars " are composed at first 
of hypertrophied connective tissue, enclosing scattered masses of 

* Ueber die^ Zellen-Infiltrationen der Lederhaut bei Lupus, Syphilis, und 
Scrofuloze. 



ORDINARY FORMS OF LUPUS. 



373 



the cell-growth, and unless ulceration occur the papillary layer may 
remain intact. But the obliteration of the glands and hair follicles 
is complete. After ulceration and healing, the papillae are more or 

Fig. 51. 




(After Auspitz.) 

Vertical section through a lupus nodule of the face, treated with dilute 
acetic acid, x 300. a. Horny layer of epidermis, b. Kete. c. Corium 
filled with cells of new formation, d. Papillary layer, e. Transversely- 
cut papilla. /. Transversely-cut vessel of corium. g. Transversely-cut 
connective-tissue bundles, h. A cut muscle, i. A sebaceous-gland coil. 

less destroyed. In ulcerating lupus, the papillary layer of the 
cutis gradually becomes exposed and is cast off, its component 
parts being in a state of fatty metamorphosis; whilst fatty de- 



374 ORDINARY FORMS OF LUPUS. 

generation of masses of the lupus tissue is observed deep down in 
the cutis. The ulcer has as its base ordinary granulations covered 
with the ordinary layers of pus. Auspitz observes that " neither the 
pus nor the base of the ulcer, nor its limitation and form, present 
any characters distinguishing it from other ulcerations arising in 
similar conditions." 

Prognosis.— The non-ulcerating forms are manageable, but 
require great attention and care. The other forms often lead to 
deformity, and are intractable to a high degree. 

Diagnosis. — In diagnosing lupus it is requisite to bear in mind 
that it occurs in young people, runs an indolent course without 
pain, is seated mostly on the face, and possesses softish vascular 
tubercles, slight scaly adherent crusts, and a gelatinous aspect of 
surface beneath them. There is no true ulceration as the rule ; 
the edge is dull red and inflammatory. There are attempts at 
repair in the shape of cicatrices; the glands are unaffected, and 
the general health is not cachectic, though it may not be good : the 
patient however may be florid. 

In some cases of acne, the sebaceous glands may atrophy, and 
depressed cicatrices are left ; but the seat of the disease, and the 
absence of tubercles, suffice for the diagnosis. 

Cancer as contrasted with lupus affects especially the lower lip ; 
it does not occur before thirty : it is painful ; its ulcer possesses 
everted, undermined edges, which are considerably indurated ; its 
surface is fungoid ; there are no attempted cicatrices ; the glands 
are diseased ; there are no crusts over the ulcer, but an offensive 
discharge, and the general health is bad. In syphilis there are the 
earthy hue and the general cachexia different from the clear skin 
of a lupus patient ; the tubercles of syphilis are larger, round, 
hard, and copper-coloured ; they have no great tendency to de- 
squamate, but tend to suppurate and to ulcerate. They are found 
on several parts of the body at the same time. The tubercles of 
lupus are flatter, softer, and covered by thin scales. Syphilitic 
ulceration is foul, dirty, sloughy, and presents a copper-coloured 
areola ; the crusts of syphilis are greenish ; the edges are sharply 
cut and everted ; in lupus with ulceration the edge is dull red, 
inflammatory, and non-everted, and the surface is not foul. 
Syphilis has also a special history and special concomitants. In 
rodent ulcer the tubercle is large ; the disease occurs in old age ; 
there is only slight tendency to healing ; the course is very chronic, 
and there is pain. 

Treatment. — It will be evident from what has been said in 
regard to the pathology of the disease that the real treatment 
consists in the destruction of the lupoid tissue by caustics. But 
general remedies are often needed to aid the cure, since lupus 
patients, especially the young, are often flabby, pale, ansemiated, 
and perhaps unable to get proper food. In a fair proportion of 
cases those attacked by lupus are phthisical or phthisically in- 
clined, and this seems to indicate what turns out to be successful — 



ORDINARY FORMS OF LUPUS. 375 

the use of cod-liver oil and iron in full doses. But then there is 
often weak digestion present in patients, and this needs to be 
remedied in the first instance by mineral acids and bitters. If 
possible, change of air should be secured the patient, who should 
sleep in a lofty and well-ventilated room, and take a large quantity 
of animal food, with more or less milk. A moderate amount of 
stimulants is also beneficial. In adults, general debility often- 
times allows a strumous or a phthisical tendency to have its way ; 
and in these cases deficient assimilation often exists. In such 
instances I have seen the best results from large doses of nitric 
acid with bitters, and nux vomica. If there be loss of flesh and 
pallor, the syrup of iodide of iron or the superphosphate with cod- 
liver oil does good. In florid subjects the mineral acids act best, 
but these, to do any real good, must be given largely. 

But I think it important to direct attention to two compli- 
cating or modifying conditions — the strumous and the syphilitic 
taints. I have spoken above of uncomplicated lupus: and of phthisis 
in close connexion with the disease. But I do not regard the pre- 
sence of a phthisical tendency in lupus patients as a complication, 
believing that these persons are, if not actually, yet potentially 
phthisical. But lupus often occurs in syphilized or strumous 
subjects, and then it is modified, as I think, by the strumous habit 
or the syphilitic taint as the case may be. Where struma co-exists 
it has seemed to me that the lupus tends to discharge and to crust 
more or less freely, and perhaps to ulcerate readily. In such a 
case certainly anti-strumous remedies do much good. Amongst 
other remedies under these circumstances, the preparations of 
iodine will be found efficacious. 

I mentioned a syphilitic taint as a complicatory condition ; but 
many instances of lupus occur at too early an age to suppose that 
this complication can have any influence on the disease in them. 
Yet in adults the case is different. Now and then I meet with 
cases of lupus in strong and healthy subjects which do well under 
the influence of mercurials administered internally. The explana- 
tion may be that the drug hastens the absorption of the new lupus 
tissue, or that the drug acts upon the syphilitic taint ; I am un- 
certain in which direction the truth is to be found. But I am 
inclined to think that some cases which are generally regarded as 
non-exedent lupus attacking the nose especially, and in which the 
deposit is pretty uniform, and the tubercles small and few and less 
vascular than usual, are in reality cases of syphilitic disease heredita- 
rily transmitted rather than instances of true lupus. I cannot avoid 
saying that occasionally I have known severe dyspepsia aggravate 
an hypersemic lupus, the latter being much benefited by the 
removal of the dyspepsia. In the ulcerating lupus Donovan's 
solution will be found useful. 

The local treatment of lupus is perhaps more important than 
the general. I am anxious to say that I am by no means sure that 
many cases of lupus in their earlier stage are not rather the woi-se 



376 ORDINARY FORMS OF LUPUS. 

than the better for the stereotyped treatment which is generally 
employed with a view to their cure. On the one hand, in some 
instances no local measures whatever calculated to check the 
increase of the disease are adopted, and so the lupus progresses 
with great rapidity, whilst the practitioner trusts to the exhibition 
of internal remedies which he thinks exert a specific control over 
the progress of the disease, but in truth only stay it in an indirect 
manner through the general improvement of health they induce. 
On the other hand, where local measures are employed, they 
sometimes, from the fact that they are used inopportunely, 
augmen trather than diminish, and certainly favour the spread of the 
disease. As I have before observed, the essential thing to be done 
is to cause the absorption of, or to destroy at once by caustics, the 
neoplasm of lupus. But there is a proper time and proper cir- 
cumstances under which this should be done. Caustics, it seems 
to me, should be had recourse to when the deposit feature is well 
marked, and when the lupus patch is not too sensitive and too 
hypersemic. I am sure it is important to recognise, quoad local 
treatment, three stages of lupus : the stage in which the congestion 
is a marked feature — this is mostly at an early date ; the fully 
developed stage or state ; and the healing stage. I believe the 
treatment of all cases of lupus, especially of the slighter and more 
superficial forms, where the congestion is marked, the patch tender 
and hot, should be an essentially soothing one. The access of air 
tends to accelerate cell changes, and where congestion is very 
active any stimulant treatment, unless it be severe, tends to increase 
the amount of blood in the part, and to accelerate the morbid 
tissue change and to spread the disease ; for if a lupus patch is 
very hypergemic, the tissues around are hyper-sensitive oftentimes. 
For some years past I have at first soothed all lupus patches, 
especially those about the face, when much congested, hot, and 
irritable ; and I know nothing better than a calamine lotion, with 
a little prussic acid and glycerine, applied several times a day, and 
the use of liq. plumbi painted on each night, which I find of 
great benefit in superficial lupus, accompanied by much vascu- 
larity. It may be necessary to touch the edge of the patch, if it 
shows signs of extending ', by some caustic, but this should be done 
cautiously. Whilst by local means one quiets the lupus patch, by 
general measures the health may be improved ; and when the lupus 
patch is less irritable and inflamed, recourse may be had to 
caustics ; but I have seen not unfrequently serious attacks of 
erythematous lupus get perfectly well by the combined use of 
internal tonics and the application externally of some mild astrin- 
gent in such a way as to secure exclusion of the external air. 
Having got rid of the congestive element of a lupus — I mean the 
congestion which is easily increased, whereby the patch readily 
becomes hot and tender, and full of blood — then is the proper time 
for the use of caustics, of which there are many. But I think 



ORDINARY FORMS OF LUPUS. 377 

in some of the minor cases, where there is a disposition to improve, 
and the tubercles are not large, that the emplast. hydrargyri, 
applied each night may suffice. But if there are distinct tubercles, 
and there is any spreading, there is no alternative but to cauterize. 
Some use equal parts of caustic potash and water, brushed freely 
over the diseased part, a poultice or a neutral unguent being 
applied subsequently. Another application is that in Formula 10. 
It is used three times a week, brushed over the patch, which is 
then covered up with lint or oil-silk. For preventing the spread of 
lupus, and destroying the tubercular form, I applied the acid nitrate 
of mercury ; for severe and long-standing cases with much de- 
posit I certainly give the preference to nitrate of zinc paste, which 
it thus made : — nitrate of zinc 3 jss, distilled water 3 j, glycerine 
of starch 3 j, wheat-flour 3 j, to make a paste. (This is one part in 
three.) For bad cases one part in two may be used. The patch 
is covered by a layer of the paste freshly made, and if much pain 
ensues a poultice is applied. The raw surface that results may 
be dressed with zinc ointment, or a little liquor plumbi rubbed 
up with adeps. When the sore has dried up, or crusted over, the 
caustic may be reapplied till all the growth is destroyed. In those 
cases in which dark crusts form, and the lupus discharges, a very 
successful plan is to clear off the scabs with a poultice, and dress 
the surface with a weak ointment of the pyroligneous oil of juniper 
3 j to 1 j of lard. If the sore spreads, or there is much thickening, 
the nitrate of silver stick should be freely applied, a la Hebra ; 
that is to sa} T , it should be pushed into the patch until it meets 
with resistance from the firm tissues beneath or around, and the*n 
used to stir up the mass of the lupus patch. It should be used 
in this manner twice a week; the operation if effective is painful, 
the pain lasting two or three hours at a time. 

The repetition of any caustic used depends upon the effect upon 
the patch, of course. In the exedent form the solid silver caustic 
and the acid nitrate of mercury are the best. They must be de- 
liberately and freely applied, and chloroform should be given if 
necessary when they are used. The chloride of zinc is preferred 
by some, the acetate by others. The latter is applied in crystal, 
and a lotion or ointment of gr. viij to f j of the substance kept 
applied subsequently. Others, again, commend nitric acid, mixed 
into a paste with sulphur, and laid on with a spatula. After caustic 
applications a poultice should be applied, and the surface dressed 
with a soothing ointment — elder flower and liquor plumbi. When 
a lupus patch is the seat of unhealthy ulceration it may be cleansed 
by the use of iodide of starch to it — a remedy which I use with 
much satisfaction in all forms of unhealthy syphilitic ulceration. 

In all cases where the disease has been arrested, and tends to 
heal, any mild stimulant or astringent application may be used, 
such as glyceral tannin, or nitrate of silver dissolved in nitrous 
ether (gr. xx — xxx to § j). It must be remembered that local 



378 LUPUS EETTHEMATODES OF THE GERMANS. 

remedies act in efficiency in proportion to any improvement in the 
general health which is brought about by our internal remedies. 1 
think it important to avoid the use of local remedies when these 
produce persistent heat and swelling, for under such circumstances 
the local applications only tend to the spread of the lupus, by in- 
terfering too much with the healthy action of the contiguous un- 
affected skin, and therefore the local reparative process. The 
disease can be made much worse by caustics. For other remedies, 
see Formulae 14, 16, 17, 20, 129, 153, et seq., 171. 

B. LUPUS ERYTHEMATODES OF THE GERMANS, OR ACNEIFORM LUPUS. 

In order to avoid confusion I repeat here that the erythematous 
lupus of the English and the Germans are somewhat different. 
The English practitioner applies the term to the most superficial 
form of lupus vulgaris, in which there are no distinct tubercular 
elevations, but in which the lupus neoplasm is thinly diffused, as 
I have described in the previous section. Hebra and his followers 
apply the designation to a form of disease which is seen about the 
face and the head, and which commences in the sebaceous glands, 
and is accompanied by the formation of new tissue in the corium, 
but chiefly in the wall of the sebaceous glands — like lupoid tissue. 
Hebra, in fact, once described the disease as a seborrhcea congestiva. 
As will appear presently, Rindfleisch regards the disease as an 
adenoma of the sebaceous glands. 

General Descriptio?i. — The disease begins generally by pajDules 
that resemble those of ordinary lupus, only that their centres show 
the opening of the hair follicles, and they are covered over by little 
scales, more or less adherent, and occasionally by slight crusts. 
As the disease advances patches are formed, which have as it were 
as a basis, the condition of the slighter forms of lupus vulgaris, 
but in which the follicles are observed to be more or less promi- 
nent, and, perhaps, slightly plugged, if the patch is not covered over 
by scales. By-and-by the central part of the patch thins from 
the deposit being removed, and distinct atrophy may eventually 
appear here and there, whilst the disease spreads at the jjeriphery by 
the formation of new papules. The whole side of the face or both 
cheeks, or in severe cases most of the face, may become diseased, and 
then the portions of the disease which first appeared have generally 
cicatrized; the surface in these spots being thin, and more or 
less parchment-like. The disease does not ulcerate as in lupus 
vulgaris. 

Neumann, in speaking of the disease as it attacks the scalp, 
observes that the diseased skin becomes bald in a circular patch ; the 
orifices of the follicles, at first enlarged and plugged with sebum, 
presently are lost to view in the scarring which follows, and the 
cicatrices sometimes ulcerate anew. The red portion of the lips 
and also the ears are, according to the same author, affected in 



LUPUS ERYTHEMATODES OF THE GERMANS. 379 

most cases at the same time, and have dry scales upon them ; the 
body and extremities being affected in rare instances, and very 
seldom the palm of the hand. 

The disease is accompanied by not a little irritation at times. 
Females of the age of twenty, or thereabouts, are more liable to it 
than others. The disease is rare before twenty, but it has been 
noticed in a child at seven years of age. 

The diagnosis of this lupus erythematodes of the Germans, is 
based upon the fact that, to the naked eye, the hair follicles and 
related sebaceous glands are seen to be the primary seats of the 
mischief — the acne-like spots being observed to stud a surface in 
other respects similar to the superficial inflltratory lupus vulgaris. 

Pathology. — It is from the German workers again that our 
knowledge of the morbid anatomy of lupus erythematodes is de- 
rived. Neumann, Rindfleisch, and Auspitz have each contributed 
ably to the subject. Neumann,* as the result of his observations 
made in the year 1S63, declares that the morbid changes in "lu- 
pus erythematodes" commence as a thickening of the walls of 
the sebaceous glands, consequent upon an increase in the connec- 
tive tissue elements, and the development of new T cells ; these 
changes occur, not only in the interior of the glands, hut also out- 
side in the tissues around. The glands become choked with 
elements, and enlarged, and then gradually lose their acinous 
structure, being presently destroyed altogether. The hair follicles 
about the hair sacs participate in the same kind of change, with 
loosening of the hair from its sheaths. But, in addition, the 
papillary layer of the skin undergoes remarkable changes. Its 
connective-tissue elements are increased in amount ; and this, to- 
gether with a certain amount of cell infiltration, causes the papillae 
to be greatly enlarged in size. The cell infiltration is also found 
in the deeper parts of the corium. Neumann further states that 
in certain cases, the cell infiltration is so extensive that the condi- 
tions of the cutis are not to he distinguished from those of ordinary 
lupus / fatty changes take place also in the new tissue, and pigmen- 
tary deposits mark the site of obliterated vessels. Neumann thus 
represents the changes he describes (see fig. 52). 

Bindfieisch,t as the result of his observations, lays great stress 
upon the limitation of the disease to the sebaceous glands. He 
declares, as it appears to me, that all forms of lupus originate as an 
adenoma of the glands. He affirms that all lupus nodules, wher- 
ever they be situated, at least in the form of the disease under notice, 
have an acinous structure. 

That in lupus erythematodes the disease is essentially an 
adenoma of the sebaceous glands, as averred by Eindfleisch, seems 
doubtful from Neumann's observations, in a case of lupus ery- 

* Wien. Med. Wochenschr. 
f Lehrbuch der Pathologischen Gewebelehre. Leipsic 



380 



LUPUS ERYTHEMATODES OF THE GERMANS. 



thematodes (German) in which the disease occurred not only on 
the face but on the palm of the hand, where no sebaceous glands 
or hair follicles exist, whilst the new growth was found about 
the junction of the rete and the cutis. I may likewise appeal to 
the observations of Auspitz,* who declares as the results of his in- 
vestigations, that in lupus erythematodes the microscope detects 
the presence of a new formation resembling the cell-infiltration of 
lupus vulgaris, but seated in different parts of the cutis, especially 
in its higher layers, as in fact Neumann has likewise observed. 




(After Neumann.) 

<Z. Enlarged papilla with cell-infiltration, b. Accumulation of cells, e. Hair (cut). 
d. Sebaceous gland with infiltration, e. Arrector pili. 

At the same time the hair follicles and sebaceous glands 
appeared to Auspitz changed in a manner similar to that observed 
in lupus vulgaris. 

Nature and Relations of L. Erythematodes. — Now it must be 
evident from the above statements that the attempt to make a 
separate variety of lupus in cases where the sebaceous glands are 

* Loc. cit., p. 16. 



LUPUS ERYTHEMATODES OF THE GERMANS. 3S1 

prominently involved in the lupus growth is an over-refinement. 
Clinically the lupus erythematodes of the Germans is simply lupus 
in connexion with a certain amount of hypertrophy and irritation 
of the sebaceous glands in the first instance, in consequence of 
which they become thickened and loaded with contents prior to 
their destruction by the new growth. This is shown to the naked 
eye by the dotting over of the lupus patch with the distended and 
plugged orifices of the sebaceous glands. In all cases of lupus the 
glands are invaded and presently destroyed ; and even in cases of 
lupus vulgaris a sebaceous gland may be seen here and there 
very prominent. I think the term lupus erythematodes a very bad 
one for the disease as it is described by Hebra, inasmuch as in some 
cases the hypertrophy of the connective tissue in the wall of the 
glands is the most marked feature, the amount of lupus cell growth 
being small : and I would much prefer lupus acneiformis, or 
adenoma lupiformis, especially as L. erythematodes is a good name, 
if wanted, for the minor non-tubercular phases of lupus vulgaris. 

Something very like the changes that are said to occur in the 
lupus erythematodes of the Germans is observed in certain cases 
of sycosis of the whiskers, in which the disease begins by sup- 
puration of the hair follicles and sebaceous glands — sometimes like 
an acne, and at others a pustular eczema — to be succeeded by 
thickening of the Avails of the follicles and the extension of the 
infiltration to the tissues generally, with subsequent atrophy of 
the tissues, together with scarring and destruction of the hair 
follicles and their related glands : the disease at the same time ex- 
tending centrifugally (see Sycosis). It may be that in some cases 
the lupiform condition may arise secondarily in connexion with 
primary changes in the follicles and sebaceous glands, and that 
this is marked in such a way in Germany as to deserve special 
recognition by the manufacture of a new variety ; but at least in 
England, I have not seen *lupus changes in connexion with the 
sebaceous glands, except in one case, so distinct or so frequent as 
to lead me to think it necessary to regard it as worthy of special 
designation. In the case to which I referred, the disease com- 
menced as a seborrhoea, accompanied by the formation of acne-like 
spots in groups, which thickened at their bases and ulcerated 
slightly ; the general surface of the diseased area assuming the 
aspect of lupus. This must be, I take it, regarded as an acneiform 
lupus. But whether the deposit is truly lupoid or only simple 
inflammatory I cannot tell, except that, like lupus, it undergoes 
degeneration and never organization. I have seen this same con- 
dition occur in connexion with scattered acne-like spots on the 
trunk, and particularly the limbs, each spot leaving behind distinct 
pitted scars. 

Treatment. — All depends upon the degree of gland implication. 
If the general infiltration of the skin is great, then the case is one 
suitable for the ordinary treatment of lupus, already given in 



382 

detail. But if the seborrhoea or acne is marked, and the general 
infiltration not so distinctly so, then I believe that milder local 
remedies are called for. One of the best, if the part is hot, irri- 
table, and tender, is a bismuth ointment, 3 j or 3 ij to an or.nce of 
lard, combined or not with a little tar or creasote. But if this be 
too stimulating, and if the edge of the patch is much reddened, 
and shows signs of extension, and there be pain, the liquor plumbi 
may be painted over the disease, or glyceral tannin applied night 
and morning for a while, and until the patch has become less 
irritable. Subsequently, unless there be much thickening, the use 
of mercurial plaster applied every night may cause the resorption 
of the newly-formed products. As it is of consequence to exclude 
the air from patches of the disease, I generally use a calamine 
lotion in the daytime. Of course if the patch is indolent and 
there be no marked hyperemia, caustics may be at once applied. 
None are better than the nitrate of zinc paste or the acid nitrate 
of mercury ; and when a sufficient depth of tissue has been de- 
stroyed, a weak iodide of sulphur or nitrate of mercury ointment 
may be used, unless it cause irritation. But during the time that 
local measures are being employed, the patient should be well 
looked after as regards general medicines, which should be ad- 
ministered according to the general principles laid down with 
regard to lupus vulgaris. I think much of cod-liver oil, and but 
a little of arsenic for these particular cases. 

CANCEROUS AFFECTIONS. 

Under this head I have to describe epithelial cancer and a 
disease allied to, if not identical with it, called rodent ulcer. It 
is generally believed that rodent ulcer is the least expressed form 
of epithelial cancer ; but as it has clinical features of some pecu- 
liarity, I shall describe it separately. 

EPITHELIAL CANCER, OR EPITHELIOMA. 

General Features. — This disease affects the face, especially the 
lower lip, the scrotum (constituting chimney-sweeper's cancer), the 
vulva, prepuce, the glands of the groin, and rarely the anus. The 
earliest sign is a little hard lump under the skin, say the lip ; it is 
flattish, hard, somewhat tender, and increases in size, so that the 
lip " pouts ; " the surface of the swelling may be somewhat pale 
or dusky, but it soon becomes slightly moist ; at other times it is 
covered by a dryish scab, or an attempt is made at " papulation ;" 
it may be in some cases fissured. The tissues around the swelling 
become more or less indurated, though they do not exhibit an} T 
evidence of change upon the surface. Ulceration now sets in in 
the shape of a little central excoriation or abrasion, and this runs 
on to distinct loss of substance until an actual ulcer is produced, 
which has an eaten-out appearance. The typical ulcer is roundish, 



EPITHELIAL CANCER, OR EPITHELIOMA. 383 

and bounded by hard, indurated, sinuous edges, which in an 
advanced stage are everted and undermined, in consequence of the 
extension of morbid action ; the base of the ulcer is dirty or 
greyish, more or less papillated ; it may be reddish and discharge 
a thin fluid, or be disposed to scab over. In cancer of the scrotum 
the development of the papillae is peculiarly marked. The disease 
in this situation commences as a small pimple or nodule, or warty 
excrescence, which remains in a quiescent state without undergoing 
much change for some little time ; it then becomes irritable, red, 
tender, excoriated, and gives exit to a slight moisture, and is 
perhaps slightly scabbed over ; the moisture increases, sometimes 
to such a degree that it is " a thin acrimonious ichor, which ex- 
coriates the surrounding skin." Very often other nodules appear 
and coalesce with the primary ones; ulceration now sets in 
in reality, the edges of the ulcer become everted, and throw out a 
luxuriant growth with scirrhous hardness, which growth moreover 
is accompanied by a discharge of very foetid, irritating matter. 
The progress of the disease is accompanied by the hypertrophy of 
the papillae, so that by-and-by — very early sometimes — the disease 
looks like a " fungous cauliflower excrescence ; " and this sprouting 
in connexion with ulceration after a while extends deeply into the 
tissue. 

Morbid Anatomy and Pathology. — On section, in an early stage, 
the mass of an epithelial cancer looks of a greyish aspect, tinged 
occasionally with yellow ; at the circumference, the boundary of 
the disease is well defined ; there appears to be special stroma ; 
what there is of stroma is formed by the tissues of the part; 
beneath the papillary layer the surface is uniform, grey, shining, 
and close-textured ; generally, the mass yields a slightly milk} 
juice, and sometimes a semi-fluid cheesy material may be scraped 
from off it. In the scrapings from the surface of the cancerous 
mass the following elements, some or all, are discoverable : — 

(a) Epithelial cancer-cells, which are nucleated, flattened, round, 
or ovalish, seldom regular, often angular in outline, and with 
processes : with granules clustering around the nucleus, which 
exhibits occasionally nucleoli, but generally granules ; the cells 
range in size from Y fa to ^Vo inch, the nucleus on an average is -5-5V0 
inch in size ; (b) nuclei about $ 1 inch, free or imbedded in a 
homogeneous blastema. These are found in the youngest part of the 
tumour. On advancing to the older parts there are found (c) brood- 
or mother-cells, containing a varying number of nuclei in different 
degrees of development ; the brood-cell is said to present a con- 
centric arrangement, this being brought about by the continuous 
enlargement of the nucleus until its outer wall comes into contact 
with that of the parent-cell ; and lastly, where the cells have been 
pressed together, especially towards the central or oldest parts of 
the individual nodules ; (d) what are called globes epidermiques, 
or laminated epithelial capsules, said to be diagnostic : they vary 



&3 



384 



EPrilI.hLlAJL CANCER, OR EPITHELIOMA. 



in size from yfg- to -g-fg- inch ; they are produced by the aggregation 
of successive layers of epithelial scales, curled one around the 
other, like a ball ; hence they look like fibrous tissue having a 
concentric arrangement : they contain granular matter, with 
tolerably visible nuclei. 

The mode in which the above-described elements are arranged, 
and the exact way in which cancer develops, has been much 
discussed of late. Some suppose — ex., Virehow — that the cancer 
cells take origin from the connective tissue. It is pretty clear, 
however, that they arise as a consequence of the abnormal 
development of the epithelial tissue. Thiersch and others, in- 
cluding Billroth, if I mistake not, hold that the epithelial cell- 
contents of the glands accumulate, together with epithelial cells 
that find their way from the rete above to the interstices of the 
connective tissue below: and that the two collections together 
form a cancerous nodule. Rindfleisch declares that if the edge of 
au epithelial cancer be carefully examined, the first thing noticed 



Fig, 53. 




a. Tumor-like 
sebaceous gland, 
inwards. 



x 150. (After Rindfleisch.) 

mass of cancer in full growth, b. An enlarged 
c. Commencing villiform projections of epidermis 



is a distinct enlargement of the sebaceous glands, which are 
extended into the tissues beneath in the shape of knotty projec- 
tions, as seen at b (fig. 53), though at the same time he admits 
that projections from the deep portions of the rete which are 
situated between the papillae — (the inter-papillary parts) — pass 
more or less deeply into the cutis, forming cell collections that 
fill alveoli formed by the normal tissues (see c, fig. 53) 



EPITHELIAL CANCER, OK EPITHELIOMA. 



385 



Koster, who is the assistant to Recklinghausen at Wurzburg, 
holds, in common with all other observers, that there is a stroma 
formed of the connective tissue of the skin, in which are embedded 
bodies of various arrangements and size, made up of epithelial 
elements. He declares, however, that there are two chief forms 
of cell collections — globular and cylindrical masses. In either of 
these " globes epiclermiques," or " cancroid pearls," or " onion- 
like booties" may be found. They are, however, often lacking, 
and then the cylinders consist of smaller, more succulent, poly- 
gonal, flat, or cylinder cells." Koster adds, that " cuts into the 
youngest part of the tumour — viz., the periphery, afford generally 
the appearance described." He further affirms that " the cancer 
bodies are not isolated in the connective-tissue stroma, but gene- 
rally connected so as to form a network ; " and he concludes that 
this arrangement is in reality due to the stuffing of the lymph 
vessels by epithelial cancer elements, the network itself being 
formed by the lymph vessels, the cancer-growth originating from 




Horizontal section through the zone of development of an epithelial 
carcinoma of the skin, showing the exposed extension of the epithelial 
projection in the system of lymph- vessels. (After Koster.) 

the cells of their epithelial lining, and the cylindrical disposition 
being explained by the filled network of lymph vessels — the 
cylinders being altered lymph vessels and their contents, as repre- 
sented diagrammatically in fig. 54 

If a portion of this network be taken and magnified, the minute 
appearances of cancer cell and globes epidermiques enclosed in a 
vessel are observed : and they are thus represented by Koster (see 
fig. 55). At the outer part of this structure are ordinary oval or 
angular nucleated cancer cells ywq to -g-oW inch, and in the interior 
brood-cells and in the centre the globes, or onion-like bodies — in 
fact, the same structures before described as being found in the 
scrapings from a cancerous tumour. 

Now Rindfleisch affirms that the disease extends by infection of 
25 J 



386 



Fig. 55. 



the lymphatics secondarily, but does not originate thus ; whilst 
Koster argues that the disease originates not in the connective 
tissue (as Virchow believes ;) not in the sebaceous glands in con- 
junction with projections of the rete 
into the cutis (Thiersch) ; but by a 
change in the endothelium of the 
vessels alone, without participation 
of the connective tissue. Koster* 
drew his conclusions from a careful 
examination of some forty morbid 
specimens. 

According to some, then, epithe- 
lioma takes origin in abnormal 
growth of the epithelial tissue of the 
skin : according to others, in cell 
growth in and about the sebaceous 
glands and the inter-papillary por- 
tions of the rete ; but according to 
Koster from the endothelium of the 
lymphatics. 

Etiology of Epithelial Cancer. 
In 90 per cent, the disease attacks 
men, and in about 90 per cent, of 
cases the lower lip ; the disease is 

ofrcylinderofepitheKal not commQn ^ after ihivt J> ancl 

cells magnified 500. a. Cylinder with its most usual time of occurrence is 

the cells and a young- and old glob- about the age of sixtv. Of 222 cases 

23, Kt"^ 6 , b ° dy) * h ' Str ° ma ' collected by Paget and Hutchinson, 

rich in cells at c. „ „ J &„ 

20v were those of men, 25 women, 
and three of the latter are known to have been smokers. The 
average duration cf life in epithelial cancer is somewhere about 
four years, when it attacks the cutaneous surface. 

The Diagnosis. — Epithelial cancer is likely to be confounded, 
when seated in the face, with lupus, syphilitic ulceration, rodent 
ulcer, and unhealthy sores about the mouth. 

Its occurrence in late life, its seat on the lower lip, its papil- 
lary ulcer, with everted, hardened, undermined edges, and the 
implication of the glands, are guides which prevent our being 
misled, as a general rule, as regards the similarity to syphilis. 
In cancer, the " sore is attended by more induration than are 
syphilitic sores ; it is usually single, while the latter are mostly 
multiple ; it causes enlargement of the glands, which tertiary 
syphilitic affections rarely do." In syphilis the history of the 
disease, the absence of the peculiar edges of the cancerous sore, 




(After Koster.) 



* Die Entwickelung der Carcinome nnd Sarcome, von Dr. Karl Koster. Erstc 
Abtheilung : Krebs der Haut (Epithelialkrebs) Alveolarer Gallertkrebs dea 
Magens. Mit 4 Tafeln Abbildugen. Wiirzburg. 1869. 



RODEXT ULCER. 3S7 

the early age oftentimes of the patient, signs of syphilis elsewhere, 
and the seat away from the lower lip, will generally guide cor- 
rectly. Lupus is a disease of yonng life, and can scarcely be mis- 
taken for cancer. Rodent ulcer occurs between the ages of fifty 
and sixty, but has never yet been seen to attack the lower lip ; it 
occurs somewhere about the upper part of the face, near the eye : 
it is slow in progress, has no tendency to affect the glands, and 
possesses no everted and no undermined edges ; its surface is not 
foul, papillary, but clean, and does not give exit to any ichor. It 
however is probably only another expression of cancer. 

The Treatment of epithelial cancer is summed up in one word — 
removal by the knife or by caustic : or both conjoined, which is the 
better mode of treatment, and the employment of a thoroughly 
tonic plan of general treatment. (See Formulae 16, 17, &c.) 

RODENT ULCER. 

Eodent ulcer has been called cancerous ulcer of the face, can- 
croid ulcer, ulcus exedens, noli me tangere. It has been pretty 
generally regarded of late as essentially a fibroid ulcer, but there 
are those who believe it to be cancer. Sir Benjamin Brodie 
remarks, in reference to it, in his " Lectures on Pathology and 
Surgery/' p. 333: "A man has a small tubercle upon the face, 
covered by a smooth skin ; he may call it a wart, but it is quite 
a different thing. On cutting into it, you find it consists of a brown 
solid substance, not very highly organized. A tumour of this 
kind may remain on the face unaltered for years, and then, when 
the patient gets old, it may begin to ulcerate. The ulcer spreads 
slowly but constantly, and if it be left alone it may destroy the 
whole of the cheek, the bones of the face, and ultimately the 
patient's life; but it may take some years to run this course. So 
far, these tumours in the face and these ulcers are to be considered 
malignant. Nevertheless, they are not like fungus nematodes or 
cancer, and for this reason, that the disease is entirely local. It 
does not affect the lymphatic glands, nor do similar tumours 
appear on other parts of the body." The disease usually attacks 
some part near the eyelids ; it is of slow progress ; there is little 
pain. The disease has been described as commencing as a 
" pimple," " a blind boil," " a small hard pale tubercle," " a 
little long cut ; " which tends to scab after a small central crack 
makes its appearance. There is in fact a small pimple followed 
by a minute ulcer. The disease extends gradually in all directions, 
but very slowly. When an ulcer forms, the edge is indurated 
and raised, but not undermined and everted ; and there is no 
infiltration of the surrounding healthy structures. The surface of 
the ulcer is dry, clean, glossy, and does not give exit to any foul 
secretion ; it is irregular in form, more or less oval, however. Sir 
James Paget says it is not warty nor granulated, and there is no 



388 RODENT ULCEK. 

upgrowth as in cancer. If a section be made, it is firm, pale 
grey, and fibrous. 

The late Mr. Moore noticed an important point in regard to 
the extension of disease. In rodent ulcer it is equal in all direc- 
tions; in epithelioma the growth tends downwards, and in two 
ways — partly, it is said, by transfer of morbid material to the 
glands in the cervical region, and partly by its more rapid growth 
on the side nearest the central organs of the circulation — that is, 
the line of transit to the heart. This Mr. Moore illustrates by 
the results of operations where, in removing a tumour, he cut 
through the cedematous tissues on the distal side, and the appa- 
rently healthy structures on the proximal side ; and the disease 
returned in the latter and not in the former spot (suffering from 
impeded circulation). This is of importance in relation to opera- 
tions. 

The disease differs clinically from the ordinary progress of 
cancer by its greater slowness, the little pain and haemorrhage, 
the absence both of any attempt at the formation of a fungoid 

frowth, and of fcetor. The glands, moreover, are never affected, 
'he ulcer may cicatrize, but the ulceration again breaks out in 
the locality of fresh deposits. The advances of the deposit and 
ulceration are unequal, hence the eaten-out or rodent appearance. 
The ulceration advances not only in extent, but in depth also, the 
cartilages resisting the most of all the tissues. The growth is 
always in one mass, not in distinct centres. To Mr. Jonathan 
Hutchinson and Mr. Moore we are specially indebted for a com- 
plete summary of all that is known of the disease. The micro- 
scopic characters are as follows : — An excessive growth of the 
fibro-cellular structure, well defined, firm, and greyish, mingled 
with fatty tissue, free fat, epidermic structures, exudation-cells, 
some of which are flattened and curled together somewhat similar 
to the globes epidermiques of epithelial cancer. Mr. Paget states 
that no true cancerous elements are present, but Mr. Moore affirms 
that he found elements like those of epithelial cancer present. 

There is one peculiar difference in the behaviour of the deposit in 
scirrhus and rodent ulcer. The growth in the former possesses 
contractility by which the relation of the surrounding parts is 
altered. That of the latter does not, so that the yet undestroyed 
parts keep their position. The same writer remarks that though 
there is no true implication of the lymphatic glands, they may occa- 
sionally acutely inflame or suppurate, but are never permanently 
indurated. 

Rodent ulcer then occurs on the face, has an indurated edge, a 
tendency to spread without respect to kind of tissue, is of slow 
progress, painless, is not related to any cachexia, never causes 
enlargement of glands, and microscopically presents characters that 
betoken it as the least expressed form of the cancerous cachexia. 
It is most common between fifty and sixty, and it does not occur 



RODENT ULCER. 389 

before thirty; generally it has its seat about the eyelids, and 
occurs in either sex equally, and it never attacks the lower lip. 

Pathology. — I have mentioned several important points in the 
above description bearing upon the nature of the disease, especially 
as regards its alliance with cancer. Mr. Moore, to whom I refer 
so much, and who wrote an admirable book on the subject,* 
inclined to the belief that rodent ulcer is not a fibrous degeneration, 
but a form of epithelial cancer, believing that as compared with 
cancer, rodent ulcer is composed " of a more feebly vital material," 
and therefore "the occasions are rare in which it imitates the 
cancerous character, by passing on to a subordinate lymphatic 
gland." Indications are found, he holds, in its microscopic history 
of the presence of cancerous (epithelioma) elements. This is, 
however, not the experience of other observers up to the present 
time. The comparative facility of extirpation is not regarded as 
an essential difference between rodent disease and cancer. The 
infiltration, too, of parts around the seat, or recognisable seat, of 
disease, is looked upon as a matter of degree : and so is the usual 
exemption of glands, upon which those who deny the cancerous 
nature of rodent ulcer lay the greatest stress, for we are told that 
" to look upon the power of inflecting glands as essential to cancer, 
would be to confound it with enchondroma or tubercle, which do 
the same, or even with skin tattooed with gunpowder." Mr. 
Moore suggests that the explanation of the non-infection of the 
glands in rodent disease is to be found in the nature of the 
diseased material itself, which is incapable of growing when 
transplanted ; and the attenuation of the natural textures, so that 
their absorbent activity is lessened, or there remains little material 
ready to pass to the glands. 

" The rodent cancer is an exquisite instance of a local ailment, 
being almost uninterruptedly continuous in its growth, from the 
solitary pimple in which it originates, over an area of half the 
face. At the same time, however, that it has every local quality 
of cancer, it is so meagre a growth that it has no superfluous 
material for circulation in the blood to distant parts, and very 
little for the lymphatics and the textures nearest to it." 

I have thus far only given the views of an English surgeon who 
paid particular attention to the pathology of the disease. 

If I turn to continental observers, I find that they make no dis- 
tinction between epithelioma and rodent ulcer. Indeed, Koster's 
observations upon Epithelioma apply equally to the two diseases. 
Mr. Hulke has recently recordedf the minute characters of several 
specimens of rodent ulcer, which plainly show the relationship 
that exists between epithelial cancer and rodent ulcer quoad 
histological features. He speaks in regard of one case of finding 



Rodent Cancer. f Path. Trans., vol. xxii. 1871. 



390 



RODENT ULCEE. 



Fig. 56. 




cells resembling those of the epidermal rete mucosum infiltrating 
the textures. " At the periphery of the hard edge and base they 
form cylinder and bud-like masses which intrude into the normal 
tissues underlying the ulcer," as exhibited in 
the annexed sketch which I made, and which 
reminds one of the figures of Koster, only 
that the cells are not pressed so closely to- 
gether, forming the globes epidermiques. 

Clinically regarded, the comparative slow- 
ness of growth, the non-implication of the 
glands, and the non-undermined edges would 
make rodent ulcer different from epithelioma : 
but the histological conditions, especially the 
fact that all the characteristic minute features 
of epithelioma have been found in the disease 
by excellent observers, tend to prove its iden- 
tity with cancer, only that it is a less active 
phase of the disease. 

Diagnosis. — " An ulcer with hard sinuous 
edges, situated on some part of the upper 
two-thirds of the face, of several or perhaps many years' 
duration, almost painless, and occurring in a middle-aged or 
elderly person of fair health and without enlarged glands, is 
almost certain to be of the rodent type." (Hutchinson.) The 
disease may be confounded with lupus, epithelioma, syphilis. Lupus 
occurs before the age of thirty, never after middle life, and always 
tends to heal. It begins as a pink, low, tuberculous elevation of 
the skin ; rodent cancer has a firm, un coloured nodule in it. In 
Iujdus there may be more than one tubercle, and the intervening 
skin may be healthy, or pink, or scaly, or oedematous ; the pimple 
of rodent cancer, on the other hand, is solitary. The surface of 
lupus first scales or peels before it breaks; the rodent cancer 
excoriates, and then scales or bleeds. Both ulcerate ; the lupus 
at one or at several of its tubercles, but the rodent cancer by the 
mere deepening of its central scabbed excoriation. Lupus may 
cicatrize and cease at any time; rodent cancer proceeds with at 
most but a temporary and partial healing near its edge. When 
both are far advanced, the lupus has a superficial appearance, 
though it have destroyed the whole nose ; rodent is precipitous 
and excavated. Lupus possesses, rodent cancer is without any, 
contractility. The margin of lupus, though thickened, is low, and 
bevelled both outwards by oedema and inwards towards the shallow 
ulceration; that of rodent cancer is firm, and is commonly, in 
both directions, abrupt. The ulceration of lupus is smooth, and 
may be multiple, being divided by scars ; that of rodent is single 
and rugged. In the vicinity of lupus there are separate, rather 
soft tubercles, and an area of pink, scaly integument ; around the 
rodent disease the skin is healthy ; and if a separate nodule do 



RODENT ULCER. 391 

exist, it is compact, firm, and in great part subcutaneous. Lupus 
is not invariably limited to the face, but may at the same time 
appear on the hands or elsewhere; rodent cancer is eminently 
local and centrifugal." (Moore.) 

Cancer in its more pronounced form occurs generally about the 
lower lip, rodent cancer never ; in cancer the glands are affected, 
the general health is bad, the ulcer is moist and gives out an ichor, 
is warty more or less, its edges are everted and undermined, and 
the parts around are infiltrated by cancerous material, and it is of 
more rapid progress. Syphilitic ulceration is more acute, there is no 
indurated solid edge, there is pus formation, the ulcer occurs often 
at an early age, the origin is not from a " pimple," and the con- 
comitants of syphilis exist elsewhere about the body. 

Treatment. — The treatment is simple and satisfactory. Experi- 
ence teaches us that extirpation by the knife, safe in the earliest 
stages, is the only successful mode of treatment : and it is effectual. 
Mr. Moore has lately shown that even in advanced and extensive 
cases the free use of caustics after as much of the disease as possible 
has been removed, is attended apparently with complete success. 
"When once the diagnosis is made, the line of procedure is easy, 
and that is the accomplishment of speedy and complete extirpation. 
General remedies are of no avail whatsoever. But there are cases 
in which the disease has far advanced, and in which it approaches 
the eye, for instance, so closely, that one is afraid of operating, and 
if the disease is quiescent the practitioner may well hesitate. I 
have seen good results from large doses of iodide of potassium and 
iron where operative measures are inexpedient — even the arrest of 
the disease for a while. But such cases as those to which I now 
refer show the necessity for effective treatment of rodent ulcer at 
the earliest period possible. 



CHAPTER XVII. 

CUTANEOUS HEMORRHAGES. 

General Remarks. — Blood may be effused into the skin under a 
variety of circumstances. The occurrence may take place as an 
idiopathic condition spontaneously ', as it has been termed: or 
secondarily in connexion with other diseases of the skin. The 
blood-vessels may be actually ruptured, and so permit the escape 
of blood, or the blood globules may escape bodily through the 
actual vessel walls. The usual cause of rupture is traumatic 
injury. The hsemorrhagic spots receive different names according 
to their size and shape. When they are small, in the form of red 
points, they are called petechia ; when larger, and more or less 
linear, vibices ; when large in the form of bruises, ecchymoses ; and 
when the blood collects in the form of a distinct tumour, hcematomata 
or blood cysts. 

The secondary forms of cutaneous haemorrhage occur in con- 
nexion with typhus, measles, scarlatina, and variola, the early 
eruptions of which may severally be more or less " hsemorrhagic," 
the hyperemia being accompanied by actual haemorrhage into the 
skin. The eruption of several of the ordinary inflammatory 
diseases of the skin also are sometimes complicated by a certain 
amount of effusion of blood ; for example, in erythema papulatum : 
in lichen, forming lichen lividus; in herpes, in pemphigus, forming 
(sanguinolent) bullae, and in connexion with the wheals of urticaria 
constituting urticaria hemorrhagica, which is generally termed^>w- 
pura urticans. Other conditions under which cutaneous haemor- 
rhages arise are altered states of the blood current, such as 
im purifications by bile products, stasis of the capillaries produced 
in connexion with kidney and heart disease, &c. 

It is only to haemorrhage occurring as a primary and inde- 
pendent disease that the term purpura is applied, and this I shall 
now describe. 

Pukpuka. — The term purpura is often applied to certain 
secondary conditions above referred to, and some little confusion 
has thence arisen, but the name should designate a disorder which 
is independent apparently of specific poison, or of chronic organic 
disease. This disease purpura may be very mild or (rarely) very 
severe. In the former case it is called purpura simplex, in the 
latter purpura hcemorrhajica. It is characterized by cutaneous 



CUTANEOUS HEMORRHAGES. 393 

haemorrhage, giving rise to spots, patches, or bruise-like discolora- 
tioiis of the skin; and in the severe form the haemorrhage also 
comes from any or all of the mncons surfaces. 

Purpura Simplex is most commonly seen in its early stage 
as a minutely fine eruption of pin-point-sized specks, of a pink 
or purplish colour, covering the skin more or less extensively, 
and accompanied by occasionally slight pyrexia. The eruption, 
which cannot be effaced by pressure, is especially apt to appear on 
the lower extremities, and it is usually most marked about the 
thighs and buttocks. In these situations there is sometimes a 
rapid aggregation of the specks into patches of irregular shape 
and size. After a few days there are intermingled with these, 
yellowish or buff-coloured patches, which are the sequelae of the 
earlier eruptions — the hues left by the fading out of the darker 
discolorations. Sometimes the purpuric spots are seated at the 
hair follicles, or they occur in connexion with some lichenous 
papules (this is the lichen lividus of Willan). Some of the con- 
tinental dermatologists describe a special phase of purpura under 
the term purpura rheumatica (or peliosis rheumatica), which is 
ushered in by rheumatic pains about the joints, and a rash-like 
erythema papulatum in different parts, which become the seat of 
purpuric effusions. But this is really only erythema complicated 
by haemorrhage: the duration and course are those of erythema 
papulatum. Actual blood sweating will be described under the head 
of Chromidrosis. 

F y urpura Hemorrhagica is purpura in an exaggerated form, taking 
the aspect in many places of irregular livid blotches : and accom- 
panied by haemorrhages from the various mucous surfaces, the 
gums, the mouth, the kidneys, stomach, intestinal tract, and the 
lungs, &c. 

Scurvy has the same general symptoms as severe purpura, but 
it however can be readily distinguished from purpura, by the 
following characteristics : — 1. It is always caused by privation of 
fresh vegetable food. 2. The gums are usually swollen, spongy, 
discoloured, and bleeding. 3. There is always great lethargy and 
prostration, and the skin is of a jDeculiar dusky., dirty-looking 
pallor. These features are not observed in purpura. 

Diagnosis. — A purple eruption, then, which is not connected 
with the exanthemata, nor with chronic organic disease, and the 
history of which does not correspond with the characters of scurvy 
just given, may be safely set down as purpura. Another point of 
diagnosis still remains. In all forms of cutaneous haemorrhage 
there is a gradual change of colour. First a more or less bright 
pink spot appears, wdiich becomes in succession purple, brown, 
tawny, buff, and yellow. It never fades on pressure. Under 
these circumstances the spot at one time may look a good deal 
like a flea-bite, but it will be found to have no central puncture. 
The spots may be single, or aggregated into patches. They tend 



394 CUTANEOUS HEMORRHAGES. 

to appear fresh every day, or at short intervals. Under the rise 
of fresh vegetable food the appearance of new spots is immediately 
checked, if the case be one of scurvy; but M purpura be the cause, 
this diet will quite fail to influence the progress of the eruption. 

Treatment. — The cause of the disease must first be ascertained. 
Nothing need here be said respecting the management of cutaneous 
haemorrhage occurring in the exanthemata, or in chronic organic 
disorder. If scurvy be the cause, the patient must be immediately 
furnished with fresh vegetable food, and good generous living. 
Lemon or orange juice, potatoes, cabbages, and lettuces are of 
especial value. The skin should be kept clean. The patient 
should be kept for the first few days in the recumbent position. 
No drugs need be given to him. The etiology of purpura proper 
is still but ill understood, and any treatment for it is therefore 
necessarily empirical. Turpentine, the perchloride of iron, and 
quinine have apparently produced the best results." (See 
Formula 167.) 



CHAPTEK XYIII. 

NEUROSES OF THE SKIN. 

Disorders of the nervous elements of the skin come under this 
head. They are characterized by alteration in the sensibility, or by 
secondary structural changes. Now disorder of the nerves of the 
surface may be secondary to various morbid conditions, and so 
altered sensibility, itching, pain, and the like, are found in con- 
nexion with or parts of many general diseases implicating the 
nervous system, in local inflammations, and indeed skin affections 
generally ; whilst structural changes, due to nerve-change, may be 
part of well-marked general disease, like elephantiasis. Nerve- 
disorder occurring under such circumstances is mostly secondary, 
and in one sense accidental ; and is therefore described in con- 
nexion with the several affections in which it occurs. In other 
cases the nerve-disorder is the prominent, primary, and practically 
the sole disease — and this independent form of nerve-disorder will 
be described here. 

The primary affections comprised under the head of neurotic 
cutaneous diseases are — 

1. Increased sensibility, Or hyperesthesia. 

2. Diminished sensibility, or anaesthesia. 

3. Perverted sensibility, including pruritus and the like. The 

changes in the skin in prurigo are probably secondary to 

nerve-disorder (see prurigo). 
It may be asked, Why not rank urticaria and herpes under the 
head of neurotic disease? For the present I have described 
urticaria as an erythematous disease, and herpes under bullous 
disorders ; for though these cannot be produced without the 
agenc}^ of the sympathetic or cerebro-spinal nerves (and the 
excitability of the nerves, one or either set, is a sine qua non as 
regards these two diseases), yet the nervous element is not the 
only one, though it is prominently involved in these diseases. And 
more information is needed about vaso-motor and trophic nerves 
before finally deciding where to group a good many diseases in 
the production of which nerves play an active part. If the mean- 
ing of the term neurotic be extended so as to admit herpes and 
urticaria it must include leprosy, in which nerve-disorder, that 
can be felt in the case of the superficial nerve-trunks, precedes 
the alteration in the skin, and is itself the consequence of the 



396 NEUROSES OF THE SKIN. 

effusion of a special fibrinous material into the cellular structures 
generally. 

Hyperesthesia, or exalted sensibility of the skin, if general, 
is secondary to brain and spinal diseases ; occasionally it is idio- 
pathic, and when this is the case it partakes of the nature of an 
hysterical pain. The skin is morbidly sensitive to all impressions — 
ex., friction of the clothes, the air pressure, and even that of lying. 

Anesthesia is infinitely rare as a primary disease, if it ever 
occurs as such. It is practically a secondary symptom of other 
diseases, such as raorphcea, atrophia cutis, &c. 

Pruritus. — General remarks. — This is characterized by the 
occurrence of " itching ;" in fact, pruritus is itching. It may 
coexist with, or be entirely unaccompanied by organic change in 
the skin ; and a knowledge of the conditions under which it 
occurs is very essential to the practitioner. 

Pruritus occurs in the first place in the course of most inflam- 
mations of the skin — ex., lichen, eczema, prurigo, lichen planus, &c. 
An exception is found in the case of those local changes in the skin 
which occur in connexion with struma, syphilis, and the exanthe- 
mata. Pruritus occurs likewise in connection with rheumatic mani- 
festations : the circulation of morbid elements, as bile, urinary 
excreta : alterations of temperature, senile decay of the skin, gastro- 
intestinal disturbance, nervous diseases, Bright's disease, genito- 
urinary and uterine derangements, sedentary habits, and stimulating 
diet ; it is also occasioned by local causes ; about the rectum, by 
ascarides and piles, and over the body in various parts by parasites 
(animal or vegetable). When pruritus is spoken of in the abstract, 
itching, as constituting the primary and sole disease present, is 
signified, and the nervous character of the itching is frequently 
shown by its sudden appearance, its almost as sudden disap- 
pearance, and often its marked tendency to periodicity. 

Pruritus may be general or local, and it is very generally fol- 
lowed by secondary changes in the skin. When general it is due 
to the causes of more general operation, mentioned above. 

When pruritus occurs, of course in most cases the patient scratches 
more or less violently for the relief of the itching, and this induces 
certain special diseased conditions. These may be stated in gen- 
eral terms to be — an intensification of existing eruptions, and 
particularly inflammatory phenomena, when these are actually 
present before ; excoriations, follicular congestion, ecthymatous 
pustules, furunculi, urticaria, some or all of these, &c. &c. — in 
fact the phenomena of a scratched skin (see p. 127) are produced, 
or what is termed a " pruriginous eruption? (not prurigo, as it is 
often erroneously called. See Prurigo, p. 160.) 

I need not enter more into detail as regards the aggravation of 
already existing eruptions, such as eczema, lichen, &c. But I wish 
to add a few words with regard to those cases in which pruritus 
exists in the first place as apparently the sole disease, and in which 



NEUROSES OF THE SKIN. 397 

scratching is practised, and eruptions follow. I refer to pruritus 
connected with senile decay (pruritus senilis), and certain local 
varieties of prurigo — viz. : P. ani, P. scroti, P. prseputii, P. pu- 
dendi. 

Pruritus Senilis. — In old people whose skin begins to exhibit 
the atrophous changes described at p. 366 the sensibility of the skin 
is much disordered and more or less associated pruritus occurs. 
!Now, in some instances the practitioner is consulted for this pruri- 
tus, and at first there is nothing else to be observed in the skin but 
laxity and thinness of the integuments, with perhaps plugging up of 
a certain number of the follicles by the exuviae shed from the seba- 
ceous glands. The pruritus is the evil from which the patient desires 
to be rid. It is increased by heat, cold, the warmth of the bed, by 
digestion, and other things. These cases may be relieved by the 
use of alkaline baths, free oiling of the surface, or anodyne applica- 
tions, such as a digitalis lotion (Formulae 51, 56, 64), or a weak so- 
lution of detergent solution of tar ; at the same time the state of 
the general system must be toned up by iron, quinine, and the like. 
But after awhile the scratching practised to relieve the irritation in- 
duces the development of distinct eruptive phenomena. A certain 
amount of hypersemia occurs, and this is followed by the formation of 
lymph papules, which being scratched, becomes pruriginous — that is 
to say, the apices are torn, a little blood oozes out and dries on these 
apices as a dark speck. These changes are followed by more or less 
infiltration of certain parts, by the intermingling of excoriations 
made by the nails with the pruriginous rash, and in some in- 
stances by ecthymatous pustules or urticaria. The pruritus is often 
intense, and takes the form of a stinging, creeping, or burning 
sensation. The pruritus is the primary, as it is occasionally the 
sole condition. The disease may be, of course, more or less 
general, or more marked in one place than the other. 

It will be seen from the above description that this malady of 
the aged consists in pruritus, together with, in addition, the effects 
of scratching, which naturally vary in degree and extent. This 
pruritus senilis must be distinguished from phthiriasis, though in 
some cases the exciting cause of the pruritus may be pediculi ; but 
when the latter are present the eruption is peculiarly limited in the 
first instance to the shoulders, and the parts about the neck, and 
there are the peculiar hsemorrhagic specks present indicative of 
the attack of the parasites. (See Phthiriasis.) 

I have this further observation to make, that in patients who 
cannot be regarded as " old," a condition like senile pruritus, with 
its consequences, may now and then, though rarely, arise. The 
pruritus is not directly the result of a decay of the skin, but of 
mal-nutrition, or of perverted innervation from worry, anxiety, 
or over headwork, or the like. 

In those cases in which eruption follows the pruritus, it is all the 
more necessary to adopt a soothing plan of treatment. If the 



398 NEUROSES OF THE SKIN. 

practitioner employs stimulants freely, or irritants, he is only in 
reality adding fuel to fire, because he is irritating an already irri- 
tated skin which is not produced by any local cause which his local 
stimulating remedies can remove: whilst soothing measures are 
needed to allay the pruritus, which itself leads to eruption secon- 
darily. But then the diagnosis of idiopathic pruritus must be cor- 
rectly made. 

This pruritus senilis above described, is one of the items that 
have been included under the term prurigo senilis. Of course in 
those cases in which pruritus is set up by general causes — ex., the 
circulation of bile products, a similar state to that just -described 
exists — viz., pruritus and a scratched skin ; but then the atrophous 
skin is absent, and the origin of the pruritus cannot be traced to 
the atrophy. 

The cure of pruritus senilis is to be effected by emollient and 
vapour baths, and anodynes, locally applied (see formulae referred 
to below). 

Pruritus Ani. — Itching about the anus arises from a variety of 
causes. It is a common consequence of piles, ascarides, tinea cir- 
cinata (eczema marginatum), the friction of the parts in stout 
people (intertrigo), gout, and uterine disorder. It occurs from 
the latter by reflex action. It is sometimes abominably trouble- 
some. The result of scratching is to give rise to the development 
of papulae, and it may be, considerable inflammatory thickening. 

The practitioner must of course discover any local cause for 
the disease, and take care to negative its operation. In cases of 
pruritus from intertrigo, I know nothing better than the continuous 
application of the unguentum plumbi co. of the old Pharmacopoeia 
(Kirkland's neutral cerate). This ointment should be spread thinly 
on rag, which should be kept in close contact with the affected 
parts, and so that these latter cannot rub the one against the other. 
In those instances in which there is very much induration, I have 
found the same plan of treatment, followed by the use of a weak 
sulphuret of potassium lotion, beneficial, provided the general 
health be carefully attended to (see formulae quoted below). 

Pruritus Prceputii is merely itching about the glans, connected 
with an abnormal secretion from the follicles of that part. The 
remedy is free washing with soap and water and the application of 
an oxide of zinc powder or lotion (see Formulae 40, 72, 88, &c). 

Pruritics Pudendi, or itching about the genital parts, is com- 
mon in women, and arises from a variety of causes — eczema, in- 
tertrigo, the presence of vegetable fungi, ovarian and uterine irri- 
tation, haemorrhoids, and varicosity of veins of the genital parts. 
In those cases in which there appears to be no structural change, 
relief is to be obtained by the locally applied anodynes, care being 
taken to treat any uterine or ovarian disease appropriately. 

A number of topical applications will be found in the Formulary 
(see Nos. 37, 38, U to 59, 76, 88, 92, 117, 131 to 137, &c). 



CHAPTEE XIX. 

CHROMATOGENOUS DISEASES, OR ALTERATION IN THE PIGMENTATION 

OF THE SKIN. 

General Summary. — In speaking of maculae under the head of 
elementary lesions, I briefly indicated the various kinds of dis- 
colorations in the skin. I have now to treat, in greater detail, of 
those which are caused by alterations in the pigmentation of the 
skin. 

Pigmentary discolorations may be divided into three main 
groups — (a) primary and idiopathic, (h) secondary or symptoma- 
tic — that is to say, pigmentations resulting from other diseases — 
and (c) congenital. 

(a.) The primary or idiopathic pigmentations result from the application of 
irritants, which set up hypersemia in some cases and in others not — as after the 
action of heat — or friction, or irritants, ex., mustard plasters, or the pressure on a 
part, as by dresses, mechanical restraints, the friction of straps, and the following- 
of certain handicrafts by which certain parts of the body are exposed to the sun or 
specially rubbed, as in masons. Scratching also will be followed in some cases by 
discoloration — this is seen in phthiriasis particularly. Hebra has well said, in 
regard to the occurrence of tanning in exposed parts, in bricklayers, stonemasons, 
coachmen, sailors, soldiers, vine-dressers, &c. , " It is precisely this localizing 
of the colouring, and its being bounded by those parts which as a rule are covered, 
that distinguish it from the varieties occasioned by internal causes ; for instance, 
change in the sexual organs. It must not be forgotten, that in those people who 
tan, there is a peculiar disposition to pigmentary deposit — a disposition exhibited 
by healthy people." Now, according to the cause of the maculations, divisions 
have been made of idiopathic stainings into traumatic, toxic, and caloric maculae ; 
but this is an unnecessary subdivision. These idiopathic stainings are generally 
localized to particular parts, and will be described in detail presently, after I have 
concluded this general summary. 

(b. ) Secondary or symptomatic stainings are those which follow in the wake of 
other diseases, or are due to disturbance of organs at a distance from the seat of 
discoloration, or as I prefer to put it, that do not constitute the essential disease, 
but are secondary to, or form only a part of, the essential disease present in any 
given case. There seem to me to be three groups of secondary pigmentations : — 
1, those which follow in the wake of and occur in the same seat as certain skin 
eruptions ; 2, physiological pigmentations connected with uterine functional 
changes ; and 3, pigmentations occurring in connexion with certain cachexias, 
the latter being associated with definite organic diseases of important internal 
organs. As regards the first of these groups, I may say that pigmentary dis- 
colorations occur chiefly after eczema — especially when the legs are attacked and 
there are varicose veins — here the blood is retarded so as to furnish ample material 
to stain ; after psoriasis, in slight degree ; after lichen planus ; after and coincident 
with all forms of syphilitic eruption, and after so-called eczema marginatum — 
really tinea circinata of the fork of the thigh and buttocks. Of course in aU these 
cases there is present the history of the several diseases to guide as to the cause. 
The seat of the discoloration is some guide, however, as to the nature of the disease, 
for the discoloration of the lichen planus is situated on the front of the fore-arm, 
about the flanks, and the side of the belly; that of "eczema marginatum" about 



400 CHROMATOGENOUS DISEASES. 

tlie fork of the thigh ; that of psoriasis, on the outside, and that of eczema, on the 
inside of the arms, &c. A careful consideration of the seat and extent of dis- 
colorations localized in the site of existing or recent eruption often helps towards 
forming a correct diagnosis of the disease which has caused it. It is in regard to 
the diagnosis between chronic eczema, psoriasis, and syphilitic eruptions that this 
staining sometimes acquires importance. Students are, however, apt to attribute 
too much importance to staining as in itself evidence of syphilis. In a case of 
w T ell-developed syphilitic eruption, the staining — coppery tint — is not needed for 
diagnosis, the character of the eruption as to shape, form, and composition being so 
much more valuable and conclusive. It is in fact not in typical but in undeveloped 
forms of eruption that staining is of value as an aid to diagnosis, and especially as 
indicative of a syphilitic taint modifying non-syphilitic diseases. But the fact of 
excessive staining or coppery-tint is no evidence, per se, of a syphilitic taint, espe- 
cially in connexion with eruptions of the leg ; for here the most marked discolora- 
tion may occur in connexion and as a consequence of long-continued congestion 
helped out and kept up by gravitation, want of tone in the tissues generally, and 
varicose veins. Where gravitation comes into play, staining or maculation of a 
marked kind goes for nothing. But there is this exception — that where there is no 
varicosity, and the maculation occurs high up near the knee without sufficient cause — 
ex. , hyperemia — to account for it, it is suspicious of a syphilitic taint ; and this leads 
me to mention the rule I observe in estimating the value to be attached to mere 
dark discoloration as a diagnostic test, in situations where gravitation does not 
come into play, of syphilis. Whenever there is staining out of proportion to what is 
generally seen under the particular circumstances present, and out of proportion to 
(that is, unexplained by) the amount of hyperemia or tissue change, and emphati- 
cally when it is an unusual feature of an eruption which is evidently modified as to 
its general characters, the modification consisting of a tendency to greater change 
or fibroid deposit in the deep parts, whilst the surface alterations are less marked 
than usual — ex. , discharge or scale formations, is less abundant — then the existence 
of a syphilitic taint may be suspected. This is an excellent practical guide. 

But I pass to consider secondary pigmentations of a physiological character. 
Hebra classes them under term " Chloasma uterinum." These stains are seen about 
the forehead, the mammae, the linea alba, the cheeks, and so on, in pregnant 
females. They are never observed before puberty. They occur in connexion with 
diseases of the sexual organs, though not necessarily do they occur under these latter 
conditions. They are not observed in females after the climacteric period is over. 

Lastly, I must note pigmentary discoloration s in association with certain 
cachexias — to wit, syphilis, malarial fevers, Addison's disease, and cancer, and 
leprosy, giving rise to an u earthy hue " in the first, a yeliow or chestnut-brown in 
the second, bronzing in the third, a sallowness in the fourth, and a dull reddish - 
brown in the last. I will just venture one additional remark or two under this head. 
The staining of syphilis is a very valuable guide indeed when it occurs about the 
face. The syphilized subject has a very anxious look, a pinched and tanned look 
about the root, sides and upper part of the nose, whilst the browmish stains are 
marked more or less on the forehead, about the cheeks and mouth, just below the 
eyes, and at the side of the face. The conjunctiva may be all the while furnished 
with a fair or even good supply of red blood. This physiognomy of syphilis is soon 
learnt, but it is difficult to describe in accurate detail. 

(c.) As regards congenital pigmentations, I need only say these are seen in moles 
and pigmentary nsevi. 

I have given the above summary with the view of furnishing a 
complete chart of pigmentary discolorations. Most of the com- 
ponents have been mentioned in connexion with the diseases of 
which they respectively form a part. I have however to say 
something further of certain of the idiopathic pigmentary affections 
which have not been described before, and which come under the 
first category in the preceding summary. 

Those cases in which the pigmentation of the skin is at fault as 
the sole existing disease may be divided into two classes — (1) 



CHROMATOGEXOrS DISEASES. 



401 



Those in which the pigment is deficient in quantity (Leucoderma), 
and (2) those in which it is in excess (Melanoderma). These may 
he congenital or acquired, general or local. The seat of change is 
the rete nmcosnm. 

Leucoderma. — This may be general or partial. The former 
condition is represented by the albino, whose whiteness is con- 
genital. The physician has only to deal medically with the partial 
variety. Now, there are two conditions producing a partial 
whiteness. In one of these cases the pigmentation is deficient in 
one spot, bnt perhaps in excess at the adjoining part ; that is to 
say, it is not equally distributed : there is no excess on the whole, 
nor deficiency, but an unequal scattering. In the other case the 
general surface of the skin is normally coloured, but there is an 
absence in some one or 
more parts locally. The 
former condition I have 
seen in young men who 
have been exposed to 
the sun in hot climates, 
and having had fever 
have returned to Eng- 
land ; it is not very 
common. The latter 
variety — that is, true 
partial leucoderma — 
occurs especially in the 



Fig. 57. 



black races, and 




fe 



^ 



sists of circular white 
patches, which have the 
effect of giving to the 
person in whom the}' 
occur a piebald appear- 
ance. (See fig. 57.) In 
leucodermic patches 
the hairs are often 
white. The only change 
in the derma is in the 
pigmentation. The der- 
ma is not structurally 
changed. Everything else is normal, save perhaps the sensation, 
which may be blunted. The extent of the patches, which may be 
round or serpentine, or in the form of bands, varies. The disease 
may cover the chest and back, white and dark blotches being 
intermingled ; it occurs in youngish folk. I cannot but think 
exposure to the sun's rays has much to do with its production, 
deranging the pigment-formation in the skin. 



tm 

n 






^ 



Leucoderma in a Portuoruese woman. * 



* From the Catalogue of the New Sydenham Society's Atlas. 
26 



402 CHKOMATOGENOtJS DISEASES. 

Leucoderma is common in India, the well-to-do natives suffering 
from it, and the question that is put to the doctor for an answer is, 
" Is this leprosy % " The hakeems are divided in opinion abont it. 
But leucoderma, consisting of white patches without any textural 
alteration, lias no relation whatever to leprosy. Dr. Farquhar's 
observations lead him to conclude that the fair-skinned individuals 
among the natives are most subject to this change of colour, and 
that leucoderma is very common about Peshawur, where the in- 
habitants have very fair skins, being for the most part immigrants 
or the children of immigrants from the fairer tracts of Central Asia. 

Diagnosis. — The fact that there is simply deficiency of the pig- 
ment without other change, save an apparent accumulation in 
parts of the skin contiguous to the white patches, is itself diagnostic. 

Pathology. — It seems clear that the disease may arise from 
depressed innervation. The action of the sun oftentimes sufficing 
to determine the occurrence of the disorder. 

Treatment is sometimes successful. A nutritious diet, a course 
of tonics — arsenic, iron, or the mineral acids — the correcting of 
any of the ill effects of the action of malarial poison, residence in 
a cool locality, and avoidance of fatigue, generally conduce to 
improvement. Locally, the use of friction and cold bathing, with 
iodine baths, are the best remedies. 

Melanoderma. — This term of course means excess of pigment 
resulting- in dark discoloration, but the altered tint of skin may 
be blue, yellowish, or black ; hence the terms cyanoderma, 
xanthoderma, and melasma. Yery short descriptions will suffice 
for these. 

Melasma, or that condition in which the discoloration of skin is 
black in colour, is general or partial. The latter is generally 
called melasma. The general discolorations associated with — as 
secondary phenomena — particular general diseases, I have al- 
ready referred to in the opening remarks of this chapter. The 
local variety, or melasma, I now notice. It may be a " physiological " 
condition, as seen in the staining around the nipple and the linea 
alba in pregnancy ; this condition may be excessive. Dr. Swayne 
has described a case in which there was a peculiar discoloration 
about the face, arms, hands, and legs, which were spotted like a 
leopard. The same woman thus affected exhibited like phenomena 
in her skin during the last three months of her two former 
pregnancies, the discoloration disappearing after each confine- 
ment. The varieties of melasma are lentigo and ephelis. I will 
briefly describe them : — 

Lentigo. — This is known as freckles. The seat of the pigment 
deposit is the rete mucosum : it is often congenital, and of varying 
extent and distribution ; generally, however, it consists of round 
yellowish spots, the size of split peas and less, not only on the parts 
exposed to the light, but also those covered by the dress. Lentigo 
occurs in those with fair skins, and particularly red-haired folk. 



0HR0MAT0GEN0TJS DISEASES. 403 

there is no desquamation, no itching, and no heat of any kind in 
connexion with freckles, which often disappear after puberty. 
Freckles do not depend upon seasonal change. They require no 
treatment, except slight stimulation, and they may be in some 
degree removed by acetate of lead and sulphate of zinc ointments, 
and iodine lotions. 

Ephelis (or Sunburn). — In this particular variety of discolora- 
tion the pigment deposit is excited by the sun's rays. Sunburn 
consists of little dots the size of pins' heads, which appear upon 
the parts of the body exposed to the influence of the sun, and are 
seen mostly in lymphatic subjects with delicate skins. Treatment 
is of little avail. The best application is a bichloride of mercury 
lotion. 

Melasmic discoloration likewise occurs as the result of the action 
of local irritants — ex. scratching, strong light, blisters. 

Pigmentary JSLevi. — These consist of collections of pigment in 
the rete and corium, and a certain amount of hypertrophy of the 
papilla at times. They may be furnished with hairs. Moles are 
of this nature. 

Xanthoderma. — In this disease the pigmentary discoloration 
is yellowish. It is characteristic of certain races, and is7 due to 
some special condition of the colouring matter of the skm, mole- 
cular or chemical. 

Cyanodeema, or blue discoloration, is different from coloured 
sweat. It is a curiosity, if not, at least in the greater number of 
instances, a hoax. A curious disease called Car ate, is described by 
Dr. Arcken as endemic in New Granada and the northern parts 
of America. It is declared to be diathetic, and characterized by 
the appearance of various colours on the body — dull white, copper, 
crimson, red, and dark blue. There appear to be three varieties — the 
simplest, blue, which is seen in persons between fifteen and twenty- 
five years of age, and consists of oval or roundish spots on the face, 
extending to the neck and lower limbs even ; the white, occurring 
in individuals between the ages of thirty and forty, rare in males, 
and usually associated with ovarian disease : this is clearly leuco- 
derma ; and lastly, the rose-coloured, consisting of red points on 
the hands, face, and belly — a variety seen in both sexes. The 
disease is said to be due to bad living. 

Pathology. — Mr. Wilson thinks that in melanoderma there is an 
ansemia of special features, accompanied by pigment deposit and 
change, due to debility of the nervous powers, and that the various 
colours are modified results. He notices especially, in reference 
to melanoderma a peculiar condition of eye — '''the melasmic 
eye." It consists of " a vivid brightness and brilliancy and 
sparkling lustre of the eyeball, a liquid depth of colour of the 
humours of the eye, and a strongly contrasting whiteness of the 
sclerotica, the effect being often increased by a more or less deep 
tint of a dull blackness of the integuments of the eyelids, more 



4:04 CUROMATOGENOrS DISEASES. 

especially of the fold of skin of the upper eyelid which immediately 
borders on the eyelashes." The non-prod action of pigment may 
arise from local destruction of rete mucosum, &c. ; from want of 
nutritive power, as in leucocythremia; and, on the other hand, an 
excessive production is brought about by imperfect oxidation — the 
carbon is not burnt off as carbonic acid ; by the imperfect elimina- 
tion of the carbon in deficient menstruation, disease of liver and 
kidneys, deficient hair formation, during disease in pregnancy 
(leucocytcsis present), and by the excessive production, from the 
use of highly-carbonized foods. Such are the causes given by 
Dr. Laycock. The above remarks apply to cases of true pigment- 
alteration. 

The Diagnosis of these discolorations offers no difficulty ; the 
colour of the skin is altered, and that alone. 

Treatment. — This is generally that of anaemia. Sometimes 
there is excessive waste going on in the system ; in that case the 
diet, the judicious use of stimulants, nerve tonics, change of air, 
mental rest, and the diminution of anxiety, are the points to 
which we should look for preventing depression of the nervous 
system, and for giving tone to the system. In this way both 
imperfect oxidation and deficient elimination are remedied. 
One otljer important thing to do is to see that the amount of 
red corpuscles in the blood is sufficient. I think that the defi- 
ciency of the red cells may be one factor in the causation of 
melasmic stains, and for that reason I use iron as a remedy 
against them. Then I am inclined to think that the action of 
the malarial poison on the system may tend to an abnormal pro- 
duction of pigment in the blood, so that in pallid neuralgic 
subjects large doses of quinine are called for. Though I do not 
think local remedies of any direct use in many cases, yet free 
ablutions, and frictions with the use of juniper tar soap as a 
stimulant, help the skin to recover its healthy condition. In 
certain cases where the pigmentary staining is of limited extent, 
it may be removed by local measures. A very good application is 
that approved by Neumann — viz., a solution of bichloride of 
mercury, 5 grains to an ounce of water. A piece of lint cut 
accurately to exactly fit the discoloured spot is to be wetted 
continuously with the solution, but the edges are to be kept in 
contact with blotting paper to absorb the excessive fluid which 
tends to collect at the sides of the piece of lint. This application 
should be made during two or three hours and then removed. 
The skin blisters and peels off. Other remedies — Iodine paint, 
uitrate of mercury, acetic acid, and nitrate of zinc paste may be 
used with almost equal success. But in some cases the result 
is disappointment: the deposit of pigment recurs, and sometimes 
semi-keloid growths spring up in the induced scar, so that great 
care is needed in treating these cases. 



CHAPTER XX. 

PARASITIC DISEASES. 

Parasitic diseases are those which are necessarily caused by the 
development and growth of parasites. They are divisible into two 
main groups: — A, Dsrmatozoic diseases, or those produced by ani- 
mal parasites ; and B, Dermatophyte diseases, or those induced by 
vegetable parasites. Of course, I do not now refer to the maladies 
connected with parasites found in the interior of the body. 

The parasitic animal or vegetable having once found a congenial 
soil, grows more or less rapidly, and in so doing produces certain spe- 
cial results, which are diagnostic : and moreover certain epipheno- 
mena or accidental superadditions in the shape of irritation of the 
skin, since in all instances parasites act in different degrees as local 
irritants in common with a host of other things. Examples of 
diagnostic lesions produced by parasites are to be found in the 
Acarian farrow in scabies, and the brittleness and disorganization 
of the hairs in the tinea. As instances of the epiphenomena, or 
accidental occurrences complicating parasitic diseases, I may refer 
to ecthymatous spots or urticaria in scabies or phthiriasis, and 
suppuration of the sebaceous glands in ringworm. 

The several points above referred to 1 shall now deal with in 
detail. 

A. DEMIATOZOIC, ECTOZOIC, OR ANIMAL PARASITIC DISEASES. 

The diseases that rank under this head are, scabies, or itch; 
phthirhtsis, morbus pedicularis, or lousiness; the eruptions pro- 
duced on the skin by the development in, or attack upon it of 
" bots," the chigoe, the dracunculns, the leptus, the flea, the bug, 
gnats, and the like. The acarus folliculorum will be incidentally 
mentioned under the head of acne. Of these, scabies, phthiriasis, 
and dracunculns disease alone require any lengthy explanation, but 
I .-hall first of all say a few words upon each of the others. 

Flea-bites. — The flea (Pulex irritans) produces a little circular 
erythematous spot, which exhibits a dark speck in the centre, that 
marks the wound made by the insect. A certain amount of irrita- 
tion is set up around the " flea-bites " in some cases, but this ge- 
nerally subsides rapidly, and ail that is left is the minute dark 
ecchymotic point, smaller than a pin's head, which gradually dies 
away. The central hemorrhagic speck surrounded by a small areola 
is characteristic of flea-bites. 



406 ANIMAL PAEASITIC DISEASE. 

Bug-eruption. — The bug {Cimex lectularius, or Acanthia lectu- 
laria) produces hypersemic papules which vary somewhat in size, 
according to the degree of swelling and irritation induced by the 
bug-bite. It may be possible to detect in the centre of the papule, 
which may be raised, circular and flattened like a bouton, a central, 
slightly red point indicating the wound inflicted by the insect, 
and under these circumstances the bug-bite may be not inaptly 
likened to a small rose-coloured wheal, the size of something less 
than a smallish split pea, flattened at the top, and with a central 
punctum. The parts about these bites feel hot, and they are 
tender, tumid, and irritable. The irritation soon subsides, to- 
gether with the swelling, and a little indurated spot is all that 
exists after a day or two. Bugs may, according to my own convic- 
tion, founded on considerable experience, not unfrequently be the 
immediate excitants of the urticaria of children (lichen urticatus, 
see p. 125). The best treatment for bug-bites is the application of 
spirit lotion, containing a little bichloride of mercury. 

A form of urticaria is said to be caused by the impaction upon 
the surface of the little hairs of some of the larvae. 

Certain caterpillars, if they get upon the skin, may excite 
urticaria also. This recently occurred to a well-known physi- 
cian from sitting under the trees in the square not a hundred 
yards from my own house. Some of the numerous caterpillars, 
which I saw in numbers about the trees, got upon his neck, and 
as he said, nearly drove him wild. The eruption was urticarial in 
character. It can be relieved by such a lotion as No. 49 in the 
Formulary. ' 

Bots. — The skin, especially in the South Americans, may be the 
seat of the development of the oestrus, the " bots," or " gadfly," as 
it has been variously termed. The larvae burrow under the skin, 
giving rise to " circumscribed f urunculoid tumours," the size of a 
nutmeg, and these tumours appear to give exit by a small aperture 
to a sanious discharge. Presently these boils open and leave ulcers 
behind. In a case reported by Dr. Duncan, there was " a little 
lump at the back of the neck, which slowly changed its position in 
various directions, then a hole opened over it, and a worm was 
squeezed out." Two or three similar occurrences took place. It 
appears that the patient (a girl) had herded some cows in Perth- 
shire. The larvse were those of oestrus bovis. Dr. Spence has re- 
corded similar cases as occurring in Shetland. " The larvse occur 
in exposed parts of the body, and in those who are loosely dressed." 
The disease is essentially characterized by the presence of little 
painful lumps, which shift about ; a little red ecchymotic line 
marking the track of the insect. The parasite is the oestrus bovis, 
belonging to the order Diptera. 

Chigoe Disease. — The Pulex or Sareopsylla penetrans, or chiggre, 
is a common cause of disease in the West Indies. The chigoe 
attacks the feet and hands, entering the skin beneath the nails or 



THE GUINEA-WORM DISEASE. 407 

betwixt the toes, either by a channel made for itself, or by the 
ducts of the skin ; it takes an oblique direction under the epidermis, 
and its track is said to be traced as an " elongated brown spot." As 
the insect gets deeper this indication of the route taken by it is 
lost. 

"The hands and feet of the parasite then become hidden beneath its own 
stomach, which enlarges rapidly, the upper part alone of the insect being per- 
ceptible through the epidermis, under the form of a milk-white spot. This 
spot enlarges considerably daily, until it looks like a large freckle, insensibly mean- 
while changing its milk-white colour to a pearly grey. By the time the animal is 
ready to deposit its eggs, it has become, says Dr. Guyon, literally all stomach, and 
this period may be known by the ashy-grey colour of the eggs, which are visible 
through their transparent envelope. The eggs now come forth one by one with 
astonishing rapidity, following each other through the layer of the epidermis, 
which reopens for them the passage previously made by the entrance of the para- 
site. The departure of the eggs brings to a termination the existence of the insect. 
It then perishes, attached entire., head, feet and stomach, to the epiderm which 
had enveloped it, and with which it is carried finally from the individual in whom 
it had fixed itself. The best time for extracting the insect is just before the emis- 
sion of the eggs ; if they are left to be hatched beneath the skin, great irritation 
and painful sores are sure to result." 

The treatment of ehiggre-disease consists in dilating the original 
channel of entrance, and carefully removing the chigoe bodily. 

THE GUINEA-WORM DISEASE. 

This disease is due to the presence and growth subcutaneously 
of the Dracunculus, or Filaria Medinensis. It is found only in 
certain tropical parts, chiefly of Asia, and Africa, and not in cold 
climates. The chief places where it is found are Senegal, Gaboon, 
the East Indies,, Bombay, Persia, Arabia Petrsea, the shores of 
the Granges, Upper Egypt, Nubia {especially about Sennaar, 
Kordofan, and Darfur), Guinea, and the Gold Coast. It has also 
found its way to Grenada and the island of Curacoa. It has been 
met with not only in man, but in the dog and the horse. It is 
much more prevalent at some times than others, especially in wet 
and rainy seasons, and after inundations, when it occurs almost 
as an epidemic. 

According to recent observations, it is rendered probable that 
some of the microscopic filaridse or tank-worms, as Dr. Carter 
styles them, gain access to the skin, and there develop into the 
Filaria Medinensis. These worms are found in stagnant waters of 
pools and swamps, where the disease is endemic. 

At the time of entry into the body, filaridse are about 3-3V0 °^ an 
inch. The average length of the full-sized worms is eighteen 
inches ; it may be much greater — three or four feet in the African 
species. The worm is milk-white, cylindrical, slightly flattened 
laterally, and tapers towards either end. It is about one-tenth or 
one-fifteenth of an inch in thickness. 

The Mode of Attach. — When the worm is very minute it finds 
its way, as before observed, to some part of the surface, generally 



408 THE GUINEA-WORM DISEASE. 

the bare feet, and " bores " its way deeply into the skin, where it 
takes up its abode. It grows for six mouths or so in a perfectly 
quiescent state, as far as the patient is concerned, and this is 
termed the " latent period," till it reaches a length of from six 
inches to two feet or more, half or two-thirds of a line in thick- 
ness, and looks like a bit of whipcord, pointed at either end. 
When it reaches a largish size, the worm begins to make its way 
to the surface, its head coming to the surface first. It then sets 
up local irritation, and a species of boil appears ; this breaks, and 
the worm protrudes ; a good deal of irritation of the general 
system follows, and the sufferer is disabled for a while. The 
worms have the power of travelling from place to place over the 
body. It is generally felt under the skin as a "cord." 

The Partioular Part of the Body Attacked. — In the vast majority 
of cases the lower extremities are the seat of guinea- worm disease, 
and generally it is the barefooted natives who are attacked. 
About 1000 cases have been collected together by a writer from 
the Indian journals, and in more than ninety-eight per cent, the 
worm was found in some part of the lower extremities, and in the 
largest proportion about the feet and the ankles. Exceptional 
conditions are readily explained either by the migration of the 
worms, or by other circumstances. The water-carriers, or Bhees- 
tees, in India, who carry a "mushuk" or leathern bag suspended 
from the shoulders, according to Ninian Bruce, are very subject 
to the guinea-worm in those parts which come in contact with the 
mushuk. Of 300 cases noted by Dr. Ilorton, in 206 the disease 
was in the feet. 

The Immediate Source of the Cause. — Much difference of opinion 
has been held in regard to the source from whence the guinea- 
worms are derived. Two things are nowadays accused as the real 
producers of the mischief : — 1. The soil and the pools ; and 2. 
The drinking water of the localities where the disease is found. 
If the drinking water contained the worms, these should be found 
in the stomach and adjoining parts, and distributed over the body, 
which is not the case ; besides, the disease occurs in persons who 
drink water of the very best kind, and in those who never take it 
at all. 

There seems little reason to doubt that the worm finds its way 
almost invariably — practically always — direct from the ground to 
any unprotected part which is brought in contact with it, and, in 
virtue of its boring properties, it effects an entrance in that part. 
The leg is the part usually unprotected and exposed, and the fre- 
quency with which the )eg is affected points to this view as the 
correct one. Then, where are the worms originally found % They 
would seem chiefly to abound in stagnant pools and swampy places, 
for there is a large amount of evidence to show that bathing in or 
tramping barefooted through ponds and pools where tank-worms 
and creatures of a similar kind exist, is followed by the develop- 



PHTHIRIASIS. 409 

ment of guinea-worm disease. Dr. Carter has given valuable 
evidence on this point, and so has Dr. Balfour in his health report 
of the Seeunderabad troops. 

The entrance of the worm into the skin of the backs of water- 
carriers is explained in a similar way. Sleeping on the ground 
bare-skinned would suffice to give the disease. It has been stated 
that Europeans are not subject to the attacks of the dracunculus.. 
This is altogether a mistake. The comparative immunity of Euro- 
peans is to be ascribed to the fact of their feet and legs being pro- 
tected by proper coverings. It is the experience of those who have 
seen much of the disease that when Europeans adopt the habits of 
natives and go shoeless, they are equally liable with the natives to 
be infested by the dracunculus. 

Treatment. — When the worm has lodged itself in the bod}' for 
several months, as before stated, it makes its way to the surface, 
and should then be seized and traction gently made upon it ; as 
much as will come forth readily, should be bound round a stick, 
or a piece of card, and fastened over the wound. This operation 
of ''winding" the worm should be repeated daily, and at the end 
of several weeks the whole is removed, and the wound heals. If 
the worm be broken, and any portion be left, the seat of disease is 
apt to be attacked by severe inflammation. Dr. Ilorton states 
that the use of assafoetida at once effects a cure, as it destroys the 
worm, and prevents inflammation and suppuration. In the case 
of the leg, where the disease is attended by much local inflamma- 
tion, it is said that amputation may be required to be performed 
to save life. The secondary results of guinea-worm disease are, 
according to Dr. Ilorton, stiff joints, contractions of the muscles, 
talipes, swellings about the malleolus, mortification of toes, en- 
largement of the scrotum and testicles, enlargement of the breast, 
and bucnemia and elephantiasis arabum. 

Dr. Ilorton has recently written an admirable essay on the sub- 
ject, containing his experience of the disease on the Gold Coast, 
and I heartily recommend its perusal to my readers, if they are 
working up the subject specially. 

PHTHIRIASIS. 

I use the term phthiriasis to denote the disordered state of skin 
which is produced by the attack of pediculi. It is distinct from 
prurigo, which I hold to be a disease wholly unconnected with the 
presence of pediculi, and which is characterized by the develop- 
ment, as primary phenomena, of fleshy papules, accompanied by 
pruritus and other symptoms of special character. Phthiriasis 
means, in fact, lousiness. 

There are three species of pediculi or lice infesting the body — 
the P. capitis, infesting the head ; the P. corporis vel vestimenti, 
or the body -louse ; and the P. pubis, or crab-louse. Hence there 
are three varieties of phthiriasis — viz., phthiriasis capitis^ P. cor- 



410 PHTHIRIASIS. 

ports, and Y. pubis. The pathognomonic evidence of the presence 
and attack upon the skin of pediculi is a peculiar hemorrhagic 
speck, as I shall describe it when I come to speak of phthiriasis 
corporis further on. In addition to this there are certain secondary 
phenomena, the consequences of the irritation set up, and the con- 
sequent scratching, and this irritation varies in degree and kind 
according to the special nutritive condition and tendencies of the 
attacked in each particular case. In one instance it will consist 
in follicular congestion alone, in another ecthyma or furunculi, 
in a third urticaria, in a fourth impetigo, as in the case of the 
scalp infested by pediculi, and so on. Pediculi, beyond the pro- 
duction of louse-marks, act in a precisely similar manner to irri- 
tants in general ; and the impetigo following or evoked by the 
presence of pediculi, depends upon the impetiginous tendency, just 
as much as an urticaria is due really to a hyper-sensitive condition 
of the nerves of the skin. 

Sometimes lice are produced in great numbers, and, it is said, 
subcutaneously. This is certainly incorrect. I will now proceed 
to particularize the various diseased conditions which result from 
the attack upon the body of the several kinds of lice. 

Phthiriasis Capitis. — The pediculus capitis (fig. 58) is found 
chiefly on the heads of uncleanly and badly -nourished children. It 
deposits its eggs, which are recognized as " nits," on the hairs, and 
Fig 58 ^ excites a greater or less degree of irritation upon 
the scalp, and in some instances about the back 
and it may be the sides, of the neck. Generally 
speaking, the eruption, excited by the irritation 
and the scratching, is an eczema; and, in pyogenic 
subjects, this assumes an intensely impetiginous as- 
pect; but, in healthy subjects, lice may give rise 
to little more than pruritus. The pediculi are 
found at the top and about the back of the head, at 
which situations the eruption is found. The head 
Pediculus capitis smells offensively, and the hair is matted together 
(female). ^ a ft[ Y ty m ass at times. The presence of "nits" 
upon the hair at once suggests the cause of the eruption. 

In some cases the pediculi excite a so-called " pruriginous " 
rash, made up of scratched follicles and small excoriations about 
the pole and nape of the neck, and occasionally small furunculi 
and ecthymatous spots. 

The Treatment. — I almost invariably use, in conjunction with 
free and repeated washing with soap and water, a weak ammonio- 
chloride of mercury ointment, containing 5 grains to the ounce of 
lard, to which some essential oil (lavender) or a few drops of creasote 
may be added, for the destruction of lice. But a variety of other 
applications may be adopted, and many of these are equally effica- 
cious. The plan of saturating the head for a day with petroleum, 
bound over with a cloth, with a good washing with soap and water 





PHTHIRIASIS CORPOKIS. 411 

to follow, as recommended by Hebra, is in vogue with some. 
Others prefer carbolic oil of medium strength. I suppose it is 
allowable for every one to use that particular remedy which he finds 
most efficacious. The " nits " may be got rid of by the use of a 
weak acetic acid lotion, 1 part to 10 or more parts of water, and 
by free washing. 

Phthiriasis Pubis. — The pediculus (see fig. 59) which usually 
infests the inguinal and pubic regions is to be found adhering to 
the hairs close to the skin, about the scrotum, mons, anus, but less 
occasionally about the thighs, the abdomen, the front of the chest, 
the axillse, and even the beard. Its attack occa- Fm 59 

sions itching, and follicular congestion, and 
it may lead to eczema, and excoriations from 
scratching, &c. The pediculus grasps the hairs 
with its fore legs, and it is not easy to detach 
the insect. The pediculus pubis is not found 
amongst children, but adults, and, as my ex- 
cellent friend Dr. McCall Anderson observes, i . 
" not uncommonly amongst the upper classes, 

who too frequently become affected from inter- 100th parts of an inch. 
course with females whose virtue is as loose Pediculus pubis, 

as their habits are dirty." The observant eye speedily detects the 
little pediculi adhering as darkish specks close to the bases of hairs 
of the regions winch are the seat of irritation. 

Treatment. — A very good plan is to drop a few minims of chlo- 
roform on a layer of cotton wool, and apply the latter to the part 
attacked by the pediculi, confining the vapour by a handkerchief 
or towel. The chloroform must not be allowed to come in contact 
with the skin, otherwise it will inflame it ; but if the vapour gains 
access to the pediculi, the latter are killed, and they may be washed 
away. It only then needs the application of a weak stavesacre 
ointment, or bichloride of mercury lotion, gr. ij to !yj, once or twice, 
or a weak vinegar lotion, to be followed up with a good washing 
or two, to get rid of all that remains of them. Some prefer to 
anoint the parts with mercurial ointment. This is an effectual 
but a messy and inelegant plan of procedure. 

PHTHIRIASIS CORPORIS. 

According to the dermatologists who hold modern views, when the 
term phthiriasis alone is used, the diseased condition signified is that 
which is produced in connexion with the presence of the pediculus 
corporis or vestimenti (see fig. 60, after Anderson). It has been 
usual to designate this state as " prurigo pedicularis," but prurigo, 
as Wilson, Hebra, Neumann, and myself understand it, has no- 
thing whatever to do with pediculi or phthiriasis. The term 
prurigo, however, is so much misused that it is necessary that I 
should be explicit with regard to its application in this place. 
The pediculus corporis, which attacks the body but lives in the 



412 



PHTIIIKIASIS CORPORIS. 




100th parts of an 
inch. Pedicu- 
lus corporis (fe- 
male). 



clothes of those whom it attacks, is of whitish colour, and may be 
half a line or even two lines in length (see fig. 60). 

The eruption caused by the attack of the 
pediculi consists of an essential or pathogno- 
monic lesion, and secondary phenomena or the 
results of irritation. It has been hitherto taught 
that pediculi bite, and certain red excoriated 
papules have been referred to as pedicnlus 
" bites." This is wholly erroneous. Pediculi 
have nothing to bite with. They are provided 
with a proboscis, with which they draw away 
blood, and the result is the production of a small 
characteristic hemorrhagic speck. This is the 
characteristic lesion. The lice, of course, set up 
considerable irritation, and the patient scratches 
for relief ; hence the occurrence of excoriations, 
eczema, papule, urticaria, pustules, and the 
like. So then it may be said that phthiriasis 
corporis is characterized by a pathognomonic 
lesion, and the results of the irritation caused 
by the itching induced, and the scratching practised to relieve it. 
1 shall notice these points in detail directly. 

Phthiriasis corporis occurs mostly in old persons and those who 
are uncleanly, but it may occur in the young, when the secondary 
results are milder than in the aged. The phenomena in ordinary 
cases, taken as a whole, vary with the length of time the disease has 
lasted and the health of the patient. The lice make their attack in 
the first place upon the parts about the neck, the clavicles, and the 
shoulders, and may be detected on the skin in lively progression ; 
they are mostly found, together with their whitish shining ova, 
in the folds of linen next the skin which come in contact with those 
parts. But when the disease has lasted some time, the whole back, 
the thighs, and the abdomen may be the seat of the produced 
eruption. The seat of phthiriasis corporis is, therefore, about the 
neck, shoulders, and clavicles, in the early stage, and the body 
generally as well in chronic cases. And the features of phthi- 
riasis vary not only with the age of the disease but the state of 
the health, but if the patient be unhealthy and cachectic and mal- 
hygieued, and scratching has been practised a long time, the re- 
sults surpass those of slight irritation. They consist not only, for 
example, in follicular congestion, but indications of severe irritation 
— ex., excessive pigmentation, urticaria, ecthymatous pustules, and 
the like. But I will now, having indicated the seat of the eruption, 
and the fact that it varies in different cases, proceed to give details. 
A. The Pathognomonic Lesion. — I have said this is a minute 
hemorrhagic speck. In order to understand how these specks are 
caused, it is necessary to refer to the anatomy of the pedicnlus. 
An elaborate article was written a year or two since by Prof. 



PHTHEIRIASIS CORPORIS. 



413 



J. C. Schjodte,* on this subject; and this 
observer clearly showed that the pediculas 
possesses a species of sucking apparatus, and 
not a mouth with mandibles. 

It seems that Swammerdam many years since 
maintained this view.f Gustav Simon, however, in his 
work on diseases of the skin,! states that Swamraer- 
dam's assertion that the pediculus is provided with 
an haustellum only, was disproved by Erichsen as early 
as 1839, who declared that there were distinct man- 
dibles and a pair of fonr- jointed palpi, and this opinion 
was supportsd, especially amongst later observers, by 
Dr. Leonard Landois. § But Professor Sohj^dte remarks 
in the first place that the general structure of thepedi- 
culus as regards its muscles, limbs, and other parts, is 
not such as would lead one to suppose it could attack 
by biting. If the head of a louse be examined from 
underneath, without a thin glass, and by reflected light 
and a low power, as Professor Schj jdte says, by alter- 
ing the focus one finds what look like mandibles, but 
which are evidently beneath the skin. To determine the 
exact structure of the head, Schjodte took several lice 
and starved them for three days ; then he put them on 
his hand to watch their attack on the skin. He tells 
us that. " as seen with the magnifier, the louse drew in 
its legs a little, arched its back, bent its head down- 
wards to the skin at an oblique angle, and projected re- 
peatedly forward and drew back through the fore end of 
the head a small, dark, narrow organ ; at last it stood 
still with the point of the head firmly abutted against 
the skin. " If the insect be now tiken away nothing k> 
seen of the projected organ, but if it be left to itself un- 
disturbed, new phenomena are noticed. At the top of 
the head, between and a little in advance of the eyes, 
a triangular blood-red point becomes visible, which ex- 
hibits rapid contraction and dilatation alternately, the 
digestive tract is also seen to be in lively peristaltic 
action, and it becomes gradually filled with blood, the 
oesophagus especially contracting forcibly. Now if at 
this stage the head of the animal is rapidly cut off just 
in front of the eyes with scissors, the structure of the 
haustellum can be seen. The excised part remains at- 
tached to the skin, but with care can be taken away, 
and if placed under the microscope it shows a short 
dark-brown protruding haustellum, provided with 
hooks at its extremity, out of which an excessively 
delicate membranous tube of varying length is hang- 
ing. If an attempt is made to examine with a higher 
power in the usual way, the protruding parts at once 
disappear as a consequence- of the pressure of the thin 
glass, and then the old image with " mandibles" and 
tw palpi" is reproduced, since the slightest pressure 
forces the protruding parts back into the head. The 
way in which this occurs is explained in detail by 
Professor Schjodte. 



Fig. 61. 




Structure of mouth of 
pediculus vestimenti. a. 
Top of head. b. Band of 
chitine. c. Hinder part of 
the lower lip. d. Protrud- 
ing part of the lower lip 
or suckers, e. The hooks. 
/. The tube formed by the 
apposition of the represen- 
tatives of the jaws ; blood 
globules are half-way along 
the tube. 



* Naturhistorisk Tidsbkrift, ser. 3, vol. hi., Copenhagen, 1864, and Annals of 
Natural History, vol. i. 1868. I have contributed a paper dealing w.th this sub- 
ject in detail to the Trans, of the St. Andrews Med. Grad. Association, vol. iv. 

f Van de Ontleeding van de Menscheluys, Biblia Naturae, i. 67. 

X Die Hautkrankheiten durch anatomische Untersuchungen erluuteit. Berlin, 
1813 ; pp. 272-4. § Kolliker's Zeitschrif t ; February, 1864. 



4:14 PHTHEIEIASIS CORPORIS. 

"It seems that the mouth is like that in the rhynchotta generally, but differs in 
the circumstance that the labium is capable of being retracted into the upper part 
of the head, and has a fold in it when so retracted. In order to strengthen this part a 
flat band of chitine is placed on the under surface, and it is thinner in the middle 
in order that it may bend and fold a little when the skin is not extended by the 
lower lip. The latter consists of two hard lateral pieces, of which the fore ends 
are united by a membrane, so that they form a tube, of which the internal cover- 
ing is a continuation of the elastic membrane on the top of the head. Inside its 
orifice are a number of small hooks, which assume different positions according to 
the degree of the protrusion, and if this is pushed to its highest point they form a 
cojlar of hooks curved backwards like barbs. The pediculus first inserts its 
labium into a sweat pore, and protrudes the lip. "When the hooks get hold of 
the parts around, then the first pair of setss (the real mandibles transformed) are 
protruded, and these are towards the point invested by membrane so as to form a 
closed tube, from which again is exserted a second pair of setas or maxillse, which 
form a tube and end in four small lobes placed crosswise. The whole forms a 
membranous tube, along the walls of which, retiform mandibles and maxillas are 
placed as long narrow bands of chitine. This tube can be lengthened or shortened 
at pleasure." 

Such is, in his own words, but condensed in substance, Schjodte's 
description of the mouth of the pediculus. The "mandibles" seen 
by Landois, Simon, and others, being the chitinous bands on the 
under surface of the head, separated somewhat by the retracted 
labium which lies on the thin central part ; the appearance of 
" palpi " is given by the barbs or hooks which fringe the orifice of 
the labium. Swammerdam's original belief is thus shown to be 
correct by Schjodte, who proves that the pediculus does not bite, 
but inserts its sucker, if it may be so called, into a pore, and so 
gets at the blood in the nearest capillary vessel. The reader will 
understand these several points if he will refer to fig. 61, which is 
a copy of Schjodte's figures given in the "Annals of Natural His- 
tory," vol. i. 1866. 

Now it is quite clear, if the above account of the anatomy of 
the pediculus, and the mode in which it makes its attack upon the 
skin, be true, .that the pediculus must produce a lesion, which is 
essentially a minute haemorrhage. As the pediculus withdraws its 
haustellum, it will leave the mouth of the follicle slightly dilated, 
and the blood will well up into the follicle, and the lesion will be 
seen in its early stage as a minute depression with a bright red 
speck of blood, the size of a pin-point or so, at its bottom. There will 
be at the outset some swelling around the hsemorrhagic effusion, 
but this quickly subsides. Presently the follicle, distended by the 
act of the pediculus in sucking, recovers its normal calibre, and there 
only remains a small speck of blood. There may be many of these 
hemorrhagic specks, and scratched follicles may be readily mis- 
taken for them, but these latter are raised and not cupped in the 
early stage. The lesion produced by the pediculus is a haemor- 
rhage, not a papule, and it has the character of an effusion of blood 
from the very outset. It differs altogether from a papule which is 
subsequently scratched, and made to present a pruriginous aspect, 
for these are too large ; and none of the excoriations, which 



PHTHIRIASIS CORPORIS. 415 

are irregular in shape and size, or the pale papulae seen in prurigo, 
are produced by the pediculi. I now never care to hunt in the 
clothes for pediculi, save for teaching purposes. The recognition 
of the lesion I have described as pathognomonic of phthiriasis 
throws a new light on the cause of many cases of children and 
young persons suffering from " pruriginous eruptions." 

B. 1 have now to speak of the secondary consequences of the 
attack of pediculi, the production of irritation and its results, which 
have only been referred to in a general sense ; and first of 

The Irritation. — This is generally intense, and partakes of the 
character of burning, or of the creeping of a multitude of insects 
over the surface. It is intensified at night by the warmth of the 
bed, and if it shows itself in one spot, it is transmitted, as it were, 
by reflex action to other parts of the body. It first occurs about 
the neck. 

The Excoriations are made with the nails. Some writers make 
much of these excoriations. Verily I have a difficulty in saying 
anything about them. Phthiriasis occurs usually in the old, whose 
skin is atrophied, and in which pruritus is readily excited ; hence the 
scratching is violent, to relieve the intense irritation ; the excoria- 
tions are deep ; at first, however, they appear as whitish or red- 
dened lines, with here and there a speck of blood about them, but 
soon the nails make way into the skin and produce well-marked 
short, but deep excoriations. 

The Eruptions Excited. — The scratching causes hyperemia of the 
follicles and hyperemia of the papillary layer ; hence in the de- 
veloped disease papules are formed first by the hyperemia and 
effusion into the follicular walls, and secondly, into the pa- 
pillary layer of the skin. The papules become excoriated by 
scratching, a drop of dried blood forming at their apices, and these 
altered papules form the so-called "pruriginous" eruption. In 
some cases effusion of serum takes place into the capillary layer 
freely, so that the little areas enclosed by the natural furrows 
of the skin are elevated, as it were, into flattish boutons, and this 
constitutes the so-called coarse urtication of phthiriasis. The 
scratching may likewise excite urticaria, eczema, furunculi, and 
ecthymatous pustules, as before observed, and these several phases 
of secondary eruptions, present in varying degree, and commingled 
with the pathognomonic lesion before described, may be classed 
together as the results of irritation. The skin, moreover, be- 
comes darkly pigmented, and covered by exuviae. The longer 
the disease has lasted the more ample and extensive will 
be the " pruritic " eruption, the ecthymatous pustules, &c., if these 
occur. 

These signs and conditions of irritation are not peculiar to 
phthiriasis, but are met with in scabies and other diseases, but 
the hemorrhagic specks I have described are peculiar to the disease 



416 PnTIIIETASIS COEPOEIS. 

under notice. In children lice may give rise to urticaria, and set 
up a " prnriginous " rash, but the ecchymatous and furuncular 
items are wanting. 

Diagnosis is readily made. The seat of the signs of irritation and 
scratching about the shoulders and clavicular regions of elderly and 
old people should invariably lead the practitioner to seek for the cha- 
racteristic hemorrhagic specks. Some difficulty may occur in regard 
to scabies, in which much scratching has been practised, but the seat 
of the eruption in scabies about the interdigits, the front of the 
fore-arm, the lower part of the belly and inner aspects of the upper 
part of the thigh, and its absence from the back and the regions 
above the nipple level, with the discovery of cuniculi, will at' once 
settle any doubt. It must be remembered that scabies and phthi- 
riasis do not by any means unfrequently occur together. 

Treatment. — A cure is quoad the actual and essential phthiriasis 
very simply and effectually accomplished by the destruction of the 
pediculi ; but it is not so easy at all times to get rid of the irritation 
and its consequeuces, occasioned by the attack of the pediculi. 

The pediculi infest the clothes and not the body, and to get rid 
of them it is only necessary to bake the clothes of the person suf- 
fering from phthiriasis to effectually destroy them. The clothes, 
and not the patient, require to be treated. The patient only re- 
quires a good warm soap-and-water bath to cleanse the skin. I treat 
all my cases at University College Hospital in this way, but then 
I have a disinfecting oven, and can use a temperature of 300° if I 
like, though 200° or 220° F. suffices. In private practice the only 
available plan is to order three or four warm baths, at intervals of 
two days, a weak ammonio-chloride of mercury ointment (gr. v. 
to 1 j) to be smeared, or a lotion containing detergent solution of 
tar (Formula 137), to be dabbed on the skin night and morning for 
a week or ten days or so, and to tell the patient to have the linen 
he wears scalded every time it is changed, which should be fre- 
quently done. The remedies above named being objectionable to 
pediculi, keep these latter away from the skin ; but it is evident that 
this is not radical treatment, but a compromise adopted to suit 
special circumstances. 

I cannot help thinking that pediculi infest not only the clothes 
worn, but the clothes of the bed of patients; but I have no proof of 
this, I admit. It is a point worthy of attention. 

Patients suffering from phthiriasis frequently require good food, 
and tonics. If much irritation be left behind, alkaline baths w r ith 
the subsequent inunction of oil and the occasional use of a prussic 
acid lotion locally applied will be of service, or even a few sulphuret 
of potassium baths in cases unaccompanied by eczema or hy- 
peremia of the skin. Eczema secondary to phthiriasis must be 
treated upon ordinary principles. 



SCABIES, OB ITCH. 



417 



Fig. 02. 



SCABIES, OR ITCH. 

This is a most important disease to be well acquainted with. 
Whilst its freqency is extreme, its features, happily, are very 
definite, and its facility of cure great. But mistakes are very fre- 
quently made in its diagnosis. Scabies is a contagions disease, 
depending essentially on the burrowing of the acarus scabiei : and 
the female insect is alone the burrower, the male wandering over 
the surface. The female acarus, in from ten to thirty minutes after 
being placed on the surface, gets beneath the skin, and busies her- 
self with the commencement of a 
canal, or amiculus, as it is called, 
in which she lays her eggs, from 
about twenty-four (Hebra) to fifty 
(Gudden). She, of course, gradu- 
ally enlarges her canal (which is 
arched) until it reaches a quarter 
to four or five inches in length ; 
the cuniculus has been observed, 
however, to be two or three inches 
long. It is curled or tortuous, 
and exhibits along its upper bor- 
der little dark specks, which are 
regarded by some as " breathing 
holes" (Gudden) ; but by others 
(Hardy and Bazin) as the excreta 
of the insect ; and by Hebra as 
dirt. The appearance is very 
characteristic. Fig. 62 represents, 
after Neumann, one of the furrows 
with contained ova. The female 
may live three or four months, 
but the persistence of the disease 
scabies depends chiefly upon the 
continuous hatching of the depos- 
ited ova. These come to the sur- 
face as the epidermis is exfo- 
liated, just about the time the 
young are ready to be hatched 




(After Neumann. ) 
Scabies burrow. The eggs next to 
which Occurs in "about a fortnight fche acarus appear partly homogeneous, 

partly granular ; those at a distance 



after each e^ is laid. The 



vounor- 



from the acarus contain embryos ; at the 



remale meets the male, becomes entrance of the burrow the fully formed 

impregnated, and then rapidly acari ma y be observed. 

burrows. The male acari, as before observed, do not burrow, but 

get under scales and crust. 

Haying burrowed, the female ensconces herself at the end of 
the furrow, scooping out as it were a little circular bed, and 
27 



418 

we may oftentimes recognise the acarus (and its halting-place) as 
a minute white speck at the end of the furrow, the borders 
of its front or head-part looking like a little dark curved line ; 
if we open this minute speck, and insert our needle, the acarns will 
cling and come away, adhering to it on removal. This acarian 
furrow now described is the certain diagnostic mark of scabies. 

The effect of the burrowing of the acarns, which is the es- 
sential cause of scabies, is to set up more or less local irrita- 
tion according to the state of the patient's nutrition. Derma- 
tologists talk of papular, vesicular, and pustular scabies ; whereas, 
the real scabies is only the acarus in its burrow — the cuniculus 
with the vesicle at one end (the result of effusion set up by the en- 
trance of the acarus), and the embedded acarus showing itself as a 
white opaque speck at the other end. All else is merely secondary to 
the irritation set up and the scratching practised for its relief. The 
papules are erected and congested follicles, the pustules suppurating 
follicles, and so on ; and these papules and pustules occur as 
a part of many other diseases in which the skin is subjected 
to severe irritation. On a healthy and clean skin no great 
amount of mischief follows ; the acari, however, delight in dirt, 
and run riot as it were on unwholesome surfaces. In the first 
degree of intensity of the disease there may be simply those con- 
ditions which only necessarily accompany and constitute the mere 
burrowing of the acarns. The patient complains of itching, having 
all the characters of that of scabies, but a diagnosis of yprxiritiis is 
erroneously made ; the little furrows are so delicate, and unac- 
companied by redness, that they are overlooked. These cases are 
very rare. The only way in which the papules can be fairly seen 
is by a side glance with the eye on the level of the skin ; they are 
fine, delicate, slightly elevated, transparent, and may contain acari ; 
the suspicious symptom is the itching at night, and a stray 
cuniculus ma} T sometimes be found. 

Under ordinary circumstances the acarus sets np effusive in- 
flammation, which may reach the stage of papulation, or vesi di- 
lation, or pustulation, and the furrow is detected running away 
from the vesicles, which are peculiar in so far as they are isolated 
and acuminated. 

Eow the acari prefer the hands of adults and the thin skin 
between the fingers ; and in these parts the disease is first seen, 
as solitary vesicles, many of which have the acarian furrow running 
away from them ; then the disease travels to the front of the 
fore- arm, the belly, thighs, and especially the upper line of the 
penis. Intermingled with the vesicles are papules and often 
ecthymatous spots, produced as a consequence of the scratching ; 
whilst linear abrasions and cicatrices are likewise formed. 

In marked cases there is oftentimes a little line of scabious 
vesicles around the lower end of the ulna, at the wrist. In the 
female, vesicles are often seated around the nipple. The eruption 



SCABIES, OK ITCH. 419 

is noticed also about the seats of pressure — ex., where a truss or 
a garter presses, above the middle of the thigh, and on the front 
aspect of the body. 

Variations in regard to the seat of scabies are readily explained. 
Acari are frequently specially conveyed — for instance, by the 
child's hand to the mam ma, by the hand to the penis, or by the 
nurse's arms to the buttocks of the child. Scabies seldom occurs 
on the face in consequence of the influence of the external cold, 
but in children there are exceptions. In children eruption, and 
especially the characteristic eruption (the vesicle and attached 
cuniculus), is often absent from the hands. Beginning about the 
buttocks, the disease is seen over the feet especially, the ankles 
and thighs, often the stomach, and the well-covered and therefore 
warm back ; when it attacks the face it may be accompanied by 
sympathetic eczema about the scalp. In children ecthymatous 
pustules are present as the rule. It is said by some that the 
acari are only found about the hands in adults, and that the erup- 
tion about the body is entirely sympathetic. This is not true. 
Hebra again thinks most of the eruption is caused by scratching. 
It arises in part from scratching, and is in part sympathetic ; 
and although acari are to be found in largest proportion about the 
hands, yet they are often entirely absent there in the child, and 
may be detected over other parts of the body. I have seen scabies 
limited to the penis and scrotum; one remarkable case recently 
came under my notice in a gentleman who was supposed to have 
syphilis, and from whose penis I got a living acarus. 

In chronic scabies we notice clinically two important facts : — 

1. That the seat of the eruption may shift itself — at one time 
the hands perhaps may be comparatively well, and then a fresh 
development of vesicles and papules occurs. 

2. The eruption may vary in intensity ; it may diminish in 
severit} 7 , and again become exaggerated, according to the hygienic 
conditions by which the patient is surrounded. In chronic cases 
the remains of the furrows are often found, as rugged lines formed 
by the shrivelled and broken walls of the furrows. This is prac- 
tically diagnostic of scabies (chronic). If we cut off the upper 
part of the cuniculus, or take the rugged walls of old canals, and 
place them under the microscope, we frequently see ova, the casts 
of, or even young six-legged acari, occasionally an acarus; and 
these diagnostic certainties are also found in abundance in 
the crusts that form in scabies. These crusts may be softened 
up by turpentine or caustic soda or potash. (See fig. 64.) 

Frequently in scabies several members of a family are attacked 
at the same time. The itching is bad at night, and evoked and 
intensified by everything that heats the body. Such is the de- 
scription of scabies itself. 

It is necessary to make special reference to the acarus that gives rise to scabies 
The female acarus, as before observed, is the most important of the two (See fig. 64, 



4:20 



SCABIES, OK ITCH. 



Fig. 63. 



central acarus.) It can be seen with the naked eye as a small, whitish, shining 
body, and is about a sixtieth or an eightieth of an inch long. On the upper surface 
it is convex, and covered with short spines directed backwards, and by which, 
when in its furrow, the insect is prevented from retreating along the channel of its 
entrance. On the opposite or lower surface in the full-grown insect there are eight 
legs, the four front ones being provided with suckers, the four hindermost with 
hairs. The head, which is capable of elongation or retraction beneath the dorsal 
plate, is somewhat pointed at its free end, fiat beneath, and widens out at the base, 
where it is implanted into the part between the anterior legs. There are two rows 
of stiff hairs surmounting the head ; the mouth is a long slit on the under surface 
of the head ; it is bounded on either side by two pairs of palpi and mandibles. At 
the base of the slit is the buccal orifice and the respiratory orifice, as stated by 
Bourguignon. The male (fig. 63) is smaller than the female. The inner pair of the 
posterior legs are provided with suckers, and the genital organs are well marked. 
The ova hatch out about the fourteenth day. The young acari have at first six 
legs ; they then cast their skin, and are provided with eight legs. 

Diagnosis. — The following are the diagnostic points in scabies, 
but the only really conclusive proof of its existence, in my opinion, 
in ordinary cases is the discovery of the furrow and its acarus. 

The seat of the secondary eruption is 
mosi suggestive, of course, being in re- 
lation with the favourite seat of the 
acari. 

1. Absence of febrile disturbance. 
2. Absence of rash from the face and 
head (this is the rule) ; its absence from 
the posterior surface of the arm or 
body. 3. The seat of the eruption: 
where the cuticle is thin — as, for in- 
stance, the interdigital spaces: the an- 
terior surface of fore-arm, front of 
the body below the nipple-level, about 
the mamma of women, along the front 
of the penis in men ; in the seats of 
pressure, as, for instance, about the 
groin when trusses are worn over the 
ischia, and about the inner line of 
the wrist forming a semi-circle; in children — the buttocks, the 
feet, especially the inner line of the sole of the foot and about the 
inner ankle, and the palmar surface of the hands. 4. The isolation 
of the vesicles, and their pointed shape. 5. The multiformity of 
the eruption — namely, the intermingling of papules, vesicles, 
pustules, scabs, and even small ulcers. 6. The itching at night, 
and the peculiar linear scratches made with the nails and fringed 
with dried blood. 7. The cuniculus or furrow. It should be 
stated that in scabies in children the cuniculi rapidly pustulate, 
and their recognition is difficult, but still they are often seen, 
8. The evidence of contagion, or the existence of the same sort 
of disease in a house or a family. It is in children that the 
greatest mistakes are made, simply from the want of knowing that 
scabies does not prefer their hands and arms, but their feet and 




Male acarus Scabiei (after 
Anderson). 



421 

their buttocks. 9. The presence of acari amongst crusts, detectible 
by the microscope. Scabies may be confounded with : — 

Lichen, but in lichen the eruption is uniform. There are no 
vesicles or pustules. Lichen occurs on the outer aspect of the 
fore- arm. The skin generally is dry, thickened, and dis- 
coloured, and though the back of the hands is sometimes at- 
tacked, the interdigital spaces do not suffer. The itching is dif- 
ferent. There are no cuniculi ; no acari, of course. It does not 
occur about the seats of pressure especially. There are no rhagades 
produced by scratching ; and the rash is seen frequently about the 
face, and often over the back. 

Phthiriasis. — In very many cases of scabies the papules become 
pruriginouSj but not to such a marked degree as in phthiriasis ; 
and this is in scabies a superadded feature only. The " pruritic 
rash " in scabies is seated about the belly and the anterior surface 
of the fore-arm ; whilst in phthiriasis the papules are scattered 
over the outer aspect of the limbs, over the back, above the level 
of the nipple-line, around the neck — in greatest profusion ; and 
about the legs. Moreover, there are no vesicles in phthiriasis, 
and no acarian furrows, but pediculi are present ; and the sensation 
is not one of itching so much as formication and burning. 

Lichen Pruriginosus. — This is simply lichen occurring in ill-fed 
and strumous children, and in consequence of being scratched the 
papules are covered at their apices with little points of coagulated 
blood. This disease lacks altogether the features of scabies as 
regards the acarus and its furrow, and the multiform aspect of the 
secondary eruption ; and it is made worse by the use of sulphur 
ointment. 

Eczema. — This differs entirely from scabies, in that it is essen- 
tially an oozing disease, in which the vesicles are agglomerated 
(and not isolated and acuminated), forming a patch of greater or 
less extent ; the characteristics of scabies are wholly wanting. Of 
course scabies may excite eczema secondarily. 

Covlplicated Scabies. — Almost any other eruption may occur 
together with that of itch. This is very important to bear forcibly 
in mind ; the co-assemblage of symptoms must be recognised. 
Secondary syphilo-dermata and scabies are frequently co-existent. 
Eczema is very often associated as a sequence, and ought not to 
offer any difficulty. Scabies in children with congenital syphilis 
may occur. Lichen is sometimes set up and kept a-going by a 
few acari. Many cases of lichen tirticatus are dependent upon 
scabies. Again, purpura and impetigo contagiosa may be asso- 
ciated with scabies. In all these cases there are generally (1) a 
history of scabies at the outset ; (2) multiformity of eruption, and 
of course intermingling of the characters of the two co-existent 
diseases ; (3) the appearance of contagion given to what is not 
generally observed to be a contagious disease. For example, a 
child may seem to catch lichen from another who has scabies; 



422 SCABIES, OB ITCH. 

the truth being that a few acari have been transplanted, and pro- 
duced lichen to such an extent as to have masked the primary 
mischief, which is only slightly expressed. It is a most excellent 
rule — one that I adopt myself — to search for scabies in all cases 
in which eruptive disease is extensive, and accompanied by much 
itching at night. 

Treatment. — Scabies does not get well spontaneously. It is neces- 
sary to treat, 1st, the scabies itself, killing the acari and their ova, 
by the application of parasiticides directly to the spots wherein these 
are located ; 2nd, to get rid of the secondary effects ; and 3rd, to 
treat the complications. In most cases, if the acari be destroyed, 
the secondary effects vanish without the employment of any 
measures against them. As a rule, the practitioner treats not only 
the essential disease — the real scabies — namely, the acarian furrow 
and its imbedded ova and acari — but also the secondary results, 
in the very same manner, applying parasiticides to the latter. Yet 
the former should be treated by parasiticides and the latter by 
soothing remedies ; the more so as the acari are generally to be 
found in certain localities. In recent eases in adults the localiza- 
tion of the acari to the interdigits and the region of the wrists is 
complete ; and it is easy to do harm by intensifying the secondary 
irritation, though the original cause (the acari) may be destroyed 
by our remedies. Therefore I say, in recent scabies use the 
parasiticides, sulphur, or storax, petroleum, benzine, or the like, 
to the wrists and interdigits, and simple unguents to other parts. 
In chronic scabies the case is different, for here the acari may be 
more or less ubiquitous as regards the body. But even here a 
distinction is to be made ; the parasiticide should be applied to the 
small and fine rash, and not to the ecthymatous pustules. 

Error number one, then, in the treatment of scabies, which is 
often made, is the application of parasiticides to " the wrong place." 
Error number two is the use of too powerful parasiticides. We 
need only use half a drachm of sulphur to the ounce of lard ; 
there is no occasion for a stronger ointment nor for hellebore 
ointment. Gentle friction for a long time with a milder prepara- 
tion is all that is required. My usual plan of procedure is as fol- 
lows. I have applied to all papules and vesicles, the following 
ointment : sulphur, half a drachm ; arnmonio-chloride of mercury, 
four grains ; creasote, four drops ; oil of chamomile, ten drops ; 
and an ounce of lard. This is rubbed in night and morning for 
three days, especially to the interdigits and wrists ; the same 
shirt is kept on till the third day, when it is changed, and a warm 
bath given. The parasiticide must not be used for too long a time. 
The use of a parasiticide for two or three days should be followed 
by a good washing, and the discontinuance of the remedies for a 
night. If the patient be not troubled with itching during the 
night we may conclude that the acari are killed, and all we need 
do is to guard against the hatching out of fresh acari by the light 



423 

application of our parasiticide once a day to any " pimply " or 
itchy place for a few days longer, taking care that the foul 
clothes are well heated or scalded. It often happens that the 
remedy used to destroy the acari is continuously used until it sets 
up on its own account severe irritation, which is mistaken for an 
increase or spread of the scabies. " Not too strong and »not too 
long " is my rule for the use of remedies in scabies. The occurrence 
of red, rough, erythematous patches is a sign that the remedy itself 
is creating a disease. 

Dr. McCall Anderson recommends storax ointment for the cure 

of scabies in preference to anything else. (See Formula No. 213.) 

Where there is much irritation I apply a calamine lotion 

(Formula No. 117) night and morning to the irritable parts, and 

administer gelatine or bran baths in addition if necessary. 

In chronic scabies I think the best plan is to give a sulphur 
vapour bath or two, but not more, as the skin becomes irritated ; 
or I sometimes use a sulphuret of potassium bath if the skin is 
very itchy and discoloured. In complicated scabies, the scabies 
should always be treated, and the parasiticide applied to every 
suspicious papule. This plan may be adopted in connexion with 
the use of remedies suited to the complicating eruption, whatever 
it may be. It should always be remembered that in complicated 
scabies a small number of acari may exist with a good deal of 
eruption. "When the scabies itself in severe cases is well, a certain 
period must necessarily elapse before the secondary eruptions can 
be cured. The process of repair takes time. The parasiticide treat- 
ment must not be pushed till all discrete eruption has subsided in 
cases of severity. The cure of scabies is judged by the decrease 
and cessation of itching and the vesicles and papules. 

A number of special formulae for scabies will be found in the 
Formulary (Nos. 189 et seq.) 

Norwegian Scabies. — In certain badly-nourished and dirty sub- 
jects, the ecthymatous phase may be very well marked in scabies, 
in the form of large dirty greenish-grey crusts covering over red 
and moist surfaces. This may be well called scabies Crustacea : it is 
seen in the sites of ordinary scabies : on examining the crusts under 
the microscope, a large number of acari, in all stages of develop- 
ment, are seen. Acari, too, exist in great numbers in the skin. 
Dr. McCali Anderson has been good enough to let me copy his 
representation. (See fig. 64.) This disease is often seen in Norway, 
and hence is called S. Norvegica. The treatment is that of ordi- 
nary scabies. 

Army Itch. — It is asserted that there exists a special form of 
itching disease among soldiers termed " army itch." In a former 
edition I quoted at some length some information in detail re- 
ceived from army medical officers relative to this disease. I do 
not think it necessary on the present occasion, since I much 
doubt the existence of "army itch" as a separate disease. I have 



424 



SCABIES, OK ITCH. 



not been able to see it. Ordinary scabies occurs amongst soldiers 
in an ordinary form, and if anti-parasiticides are too vigorously 
used, it is succeeded by a " pruritic " (pruriginous) rash, which 
does not readily subside. Scabies is not treated now-a-days so 
vigorously as it was, and this secondary eruption (pruritic) is not 
so frequently met with. Further, phthiriasis is commo'n some- 
times amongst soldiers on the campaign, or if badly hygiened, and 




^ x -V.-; - o*>- >' i c^*"" 



Crust from a case of the so-called Scabies Norvegica. a a a. Eggs of 
the acarus in various stages of development. b b. Egg-shells, c c. 
Fragments of acari. d. Female acarus e. Larva. The little oval or 
irregularly-shaped masses are supposed to be excrement. 



this is accompanied by a pruritic rash. Lastly, follicular conges- 
tion and its consequences (see Follicular Hypersemia, p. 127) are 
very likely to occur under conditions of irritation in those whose 
skin has been disordered by " prickly heat," or who have resided 
in warm climates, especially if they are dyspeptic. The pruritic 
rash is then exaggerated by the use of flannel, sea-bathing, beer, 



VEGETABLE PARASITIC DISEASES. 4:25 

exposure to alternations of temperature, and the like. I suspect 
therefore that badly-treated itch, phthiriasis, and pruritic rash, 
consequent upon perverted innervation of the skin, make up the 
item, " army itch." The treatment consists, in the first place, of 
soothing remedies ; in the second, in destroying the pediculi ; and 
in the third, in the removal of dyspepsia, the exhibition of alkalies 
and a mild course of Donovan's solution, with locally the employ- 
ment of alkaline and emollient baths and soothing lotions, such as 
are given in Formulae 44, 45r/, 54, 56, 68, 87, 117. 

Eruptions Excited by Gnats. — I have met with a small 
species of tick in man ; whether it causes disease or not, I 
do not know of my own personal observation. Various species 
of gnats are apt to inflict wounds, especially in the summer- 
time, which resemble musquito-bites. Musquitoes have not 
been known to exist in England. The so-called musquitoes, 
whose existence in England and other places has recently been 
asserted, are probably all British gnats. The females of the 
common gnat (Culex pipiens) every summer, after hatching out 
from w T ater-tanks and open ditches around houses, attack the 
exposed parts of the body, and there are many other species of 
the same genus Culex. The musquito of the Riviera is also a 
Culex. But there are midges, some of which are called sand- 
flies, which inflict wounds on the body. Such is the opinion of 
Professor Westw ood. Erythematous " bumps " caused by the 
bites of gnats may be treated with a weak solution of bichloride 
of mercury or carbonate of ammonia. 

I now come to the second great division of parasitic diseases — 
viz., those produced by the development of vegetable parasites 
belonging to the genus fungi, and named 



B. DERMATOPHYTE, EPIPHYTIC, OR VEGETABLE PARASITIC 

DISEASES. 

I have called these diseases generically, in the group — Tinese; 
a mode of designation accepted and adopted in the new nomen- 
clature of disease sanctioned by the College of Physicians. It 
may be expected that I should give an elaborate account of these 
diseases, but it would occupy the space of an entire book to do 
this satisfactorily. I shall therefore content myself with a practical 
account of the subject. Now fungi getting upon the surface may 
or may not flourish. When the soil is suited to their growth, they 
produce most definite lesions, perfectly characteristic, especially 
in hairy parts. The same fungi as those which attack the surface 
of man invade the hard structures of a very large number of the 
lower forms of animal life, and attack parts analogically the same 
as those attacked in man. 

I hold that nothing but the ravages of a fungus can produce the 
peculiar changes w T hich are seen in the hairs and epithelial tissue in 



426 VEGETABLE PARASITIC DISEASES. 

the tinese. I do not know of any disease other than a tinea in 
which fungi are present, and in which the hairs are loosened and 
rendered dry and brittle, or in which the epithelial cells are 
affected in such a way as to give rise to the conditions observed 
in chloasma. 

Fungi will not flourish on a healthy surface, but grow upon those that are 
most prone to a non-specific eruption ; and for this reason vegetable parasitic 
diseases occur in young life, diminishing rapidly in frequency as adolescence 
advances. But inasmuch as there is one variety of ringworm infinitely more 
common than others, and to which any general remarks on this question I might 
make will apply with double force, I shall postpone what I have to say about the 
soil suited to the growth of fungi till I come to speak of tinea tonsurans. 

General Structure of the Fungi. — I now speak of the characters of the parasitic 
fungi growing upon man in a general sense, reserving the description of individual 
parasites to be included in that of the several diseases in which they are found. 
Parasitic fungi found on man are often made up of minute cells alone, but as a 
rule of cell-productive bodies, called conidia and mycelium. 

1. Conidia (reproductive bodies), commonly called spores. These are round or 
oval, having an average size of '006 mm. , but the size varies much ; the conidia 
may be solitary or arranged in rows which are single or many filed, or they may 
be collected together in groups of various sizes. These conidia often show a dark 
spot, an actual nucleus, or granular nuclei, in their interior. They are double 
contoured, often constricted, and the halves may be unequal or equal in size. 

2. Chains of the some Conidia, ichich hare a more or less Beaded Appearance. — There 
is a real union between the component cells, and the rows are moniliform, or 
multiple. They may give off branches in various directions. These forms usually 
receive the name of sporidia, or sporule-bearers. Within the component elements 
or cells are found clear contents or granules, or, if large, actual cells. 

3. Thread* ( mycelium) of very carious Shapes and Sizes. — The least expressed form 
is that of a fine transparent filament. But there are stages between this and large 
double-contoured tubes. The contents of the tubes are usually granules and cells. 
The tubes are often not uniform in diameter, being more or less constricted, and 
the interior space is partitioned by septa. The filaments sometimes interlace in a 
very free manner, and may bear, in rare instances, at their extremities various 
forms of fructification, either with the form of an enlarged terminal solitary cell or 
a shortly- jointed tube, or a clustering of conidia seated upon a receptacle or a 
radiate arrangement of conidia, &c. These tubes and threads are called thcdlus- 
fibrils. 

4. Stroma. — This consists of an infinite number of minute cells, which are pro- 
bably derived from the multiplication of granules in the interior of cells and fila- 
ments, and is the early condition or nuclear form of the fully-developed fungus, 
accompanies all fungi in a state of active growth, and is oftentimes well seen in 
tinea favosa. It is generally overlooked, aud requires a high power for its detec- 
tion. It is very potent for evil. 

The structure of the spore is very simple. It has an outer coat or envelope 
composed of cellulose, and an inner one, or utricule, enclosing a liquid which con- 
tains floating granules, and is coloured blue by iodine. 

Diagnostic Features of Fungus Elements. — The conidia maybe confounded with 
many other cells. With fat globules, blood discs, corpuscles of various fluids, 
young epithelial cells, or rather their nuclei, pus, and earthy particles. The effect 
X)f re-agents will, however, prevent error. The conidia are unaffected by ether, 
chloroform, and spirit of wine, which dissolve fatty cells, and render epithelial 
tissues transparent. Ammonia renders the conidia perhaps a little more colourless, 
whilst it dissolves pus and the secretion of many eruptive diseases (which contain 
small granules and cells somewhat resembling large conidia) " converting them into 
a gelatinous mass." Impetiginous crusts, fat, pus, globules, hair, and epithelium 
are dissolved when heated in a hot solution of potash, especially if a little alcohol 
is added. 

The greatest care must be taken on every occasion to distinguish between fatty 
cells and conidia, and diffused molecular fat anl sporules or the nuclear form of 
fungus ; indeed this is the important practical point requiring attention clinically, 



VEGETABLE PARASITIC DISEASES. 427 

and really it is a difficult thing oftentimes fairly to get rid of the fatty matter. If 
we suspect the presence of much fat, it is advisable to allow the hair or other 
object to soak for some time in ether— if in fact the least doubt exists as to the na- 
ture of any particles, cells, or granules. The fat cells always exhibit a wide varia- 
tion as regards size, and have a duller aspect ; the cells of the fungus, on the other 
hand, are uniform in size in any particular case ; they refract the light very per- 
fectly ; their outline is more defined and contoured ; they are not affected by ether ; 
and they contain a nucleus or granule which may require, however, a high power 
for their definition. In old-standing cases of tinea, the epithelial cells take on a 
kind of fatty degeneration, and look very like cells invaded by sporules. 

When the mycelium is well developed, it cannot be mistaken very well for any- 
thing else, but there are one or two foreign matters and modifications of normal 
structure that offer appearances similar in aspect to some of the less flourishing 
examples of mycelial threads. I have known the fibres from handkerchiefs or towels 
which have been used to cleanse the object-glass to be recognized as mycelial 
filaments. Sometimes some of the fibres of the hair will be stripped of the shaft 
and curl back like mycelium. The edges of cells are dark, and never have a clear 
central. line, do not branch, and do not contain granules. The safeguard is to get 
the mycelium free from surroundings, and then no error can arise. The imbrica- 
tion of the epithelium is sometimes irregular, and the edges of the scales present 
exactly the appearance of mycelium running transversely through and across the 
shaft of the hair, and it is really difficult to imagine that filaments are not present, 
more especially if there happen to be a few sporules scattered throughout the in- 
terior of the hair. By careful observation, however, the outlines of the cells may 
be traced not only over, but beyond the area of the hair. 

In examining for fungus elements a hair shotdd be extracted from a diseased 
patch, and placed at once in a little diluted liquor potassa) (to render the parts 
transparent), then covered by a piece of thin glass, without the use of any pressure, 
and put under the microscope. Then if it be necessary to examine it more minutely, 
the parts may be carefully dissected with a needle. As a rule, harm is done by 
rubbing or squeezing the preparation between the two glasses. To get rid of the 
fatty matter, it is best to soak the hair in ether, and then to wash it thoroughly 
before adding liquor potassaa. In the case of furfuraceous desquamation, those 
scales which are situated at the edge of the diseased patch should be selected and 
treated in like manner, without using pressure, and as small an amount of the epi- 
thelial matter as is convenient should be subjected to examination. 

I have before observed that the stromal or minute form exists in abundance very 
frequently, and is not discovered ; the fibres of the hair concealing the small cells. 
If the hair is allowed to soak for a while in alkalies, the cells may be more readily 
seen, and in warm weather the minute form of fungus will develop in glycerine 
and water in a few days to a recognizable size. The stromal form may be mis- 
taken for pigment-granules ; but the latter are uniform in size, do not refract the 
light, and there is no accompanying damage to the hairs when they are present, 
and with a high power the granules do not appear translucent. "When in doubt, 
I at one time was in the habit of employing artificial germination to assist in 
solving the difficulty. The following figure represents 
the appearance presented by the stromal form of fungus 
after being ''put up" in glycerine for a few days. On 
the first examination only the faintest trace of the cellules 
was visible. 

Mode of Discovering Fungi. — Many persons find the 
discovery of the fungi in parasitic diseases a difficult 
matter. The main reasons why the fungi are not detected 
are as follows : — 

(1.) From having too large a mass under examination. 
Thin sections or layers of epithelium or hair should 
be taken. (2.) The non-use of re-agents to render the suspected tissues more 
or less transparent. (3.) Too much manipulation is practised, and thereby 
conidia are sometimes rolled up, as it were, in epithelial layers softened and 
altered by re-agents, and thus concealed. (4.) The presence of pigment in 
large quantity may conceal the fungus elements. (5.) Ill selection of hairs 
and scales. It is very possible to extract for examination a healthy hair which 
stands in the middle of diseased ones ; diseased hairs are loosened in the follicle, 




428 VEGETABLE PARASITIC DISEASES. 

and altered in texture, dry, and brittle. (6.) The fungus may be left behind in 
the follicle, the hair coming away without it. (7.) Secondary changes are often 
mistaken for the real disease ; for example, a scaliness may result from the irrita- 
tion of a fungus not in the actual seat of the scaliness, but in parts near, and 
the absence of the fungus from the same scales is no sign that the parasite is not 
the indirect cause of the scaliness. (8.) The stromal minute form of fungus is 
mostly overlooked. 

The Mode of Entry of the Fungus into the System.— There is no difficulty in ac- 
counting for the access of germs to living bodies, for these g-erms are freely dis- 
tributed and disseminated in the air. A good illustration of this fact may be noted 
in the experiments of M. Bazin {Gazette Med. de Paris, July 30, 1864), which con- 
sisted in passing currents of air over the head of a f avus patient, and thence over 
the open mouth of a jar containing ice. The ice cooled the air, causing the depo- 
sition of moisture, in the drops of which the achorion sporules were detected. The 
same thing may be shown by holding a moistened glass slip near the head of a 
patient, and just rubbing his scalp freely. Of course, actual contact is much more 
effectual in the implantation of germs. I have myself detected fungus elements in 
the air of a school in which a good number of children were suffering from ordinary 
ringworm, and the reader will find the details in the section headed lt Ringworm in 
Schools," further on. But supposing that the sporular elements find their way to 
the human surface, it maybe asked, how do they get beneath the tissues? In 
various ways probably. The fungus elements may enter by fissures or natural 
orifices ; for example, in ordinary ringworm the sporules lodge themselves at the 
opening of the hair follicles, and put out fine filaments that make way amongst the 
tissues. The growing mycelial thread forces itself more and more beneath the 
layers of the superficial tissues ; or processes may shoot out from the spores them- 
selves, and enter beneath the epithelium ; or the spores may be enveloped and car- 
ried bodily inwards ; or enter by traumatic lesions. In each and every instance the 
germs of parasites are derived ab externo and not generated spontaneously. 

The Transmission of Parasitic Disease from Animals to Man. — There can now be 
no doubt in the mind of any dermatologist who has made himself acquainted with 
even the scanty literature of this subject, that parasitic disease, especially favus. 
is frequently, and in some sense freely, transmissible from animals — ex., the calf, 
the ox, the horse, mice, and cats — to the human subject. I shall not fail to men- 
tion facts in detail in speaking of favus and tinea tonsurans. I am informed, upon 
good authority, that the transmission of ringworm to men is of very frequent oc- 
currence in Australia, the milkers of cows especially being largely affected. Dr. 
Frazer {Dub. Quart. Journ. of Med. Sc'ence, May, 1805) has contributed a good 
paper to the subject, entitled, "Remarks on a common Herpetic Epizootic Affec- 
tion, and on its alleged frequent Transmission to the Human Subject," containing 
cases. I can confirm by my own experience the truth of the statement that mice 
with favus can communicate the disease to the cat, and the cat may give favus, or 
even tinea circinata, subsequently to the human subject. See also the Veterina- 
rian for 1871 and 1872. 

The Principles of Treatment in parasitic diseases. — The main aim in all cases is 
to remove or destroy the parasite, and as this is found in and around the hairs, it may 
be in great measure removed by what is called epilation — that is to say, the extrac- 
tion of the hair with tweezers en masse, but as the hairs are brittle, in the attempt 
they frequently break off, leaving their stumps behind, loosened, and perhaps filled 
with conidia. Still this imperfect kind of epilation is needed in severe cases, 
where the disease is deep, and it is desirable that some agent should be at the 
same time employed to destroy the fungus in and about the follicles, for at the 
time of epilation greater access to the interior of the follicle may be attained. 

In slighter forms of parasitic disease, and in those which are recent — that is to 
say, where the fungus had made its way into the structures only a short way — 
the destruction of the fungus may be readily and easily secured, simply by the use 
of what are called parasiticides. In certain of the slighter forms, general remedies 
are scarcely needed, but in other instances, where the disease is extensive, and the 
fungus luxuriant, the constitutional condition is clearly one that is peculiarly fitted 
for the growth of parasites, and some evidence of its nature may be gained by 
enlarged glands, a pale, pasty, flabby countenance, a certain amount of anaemia, 
want of flesh, disordered bowels, and such like symptoms, clearly indicating that 
assimilation is at fault. In such cases the cure is expedited considerably by the 
use of iron, quinine, and especially cod-liver oil in the upper classes, and the same 



429 

remedies, with, cleanliness, a proper amount of fresh air, and an increase in the 
meat diet in those lower in the social scale. But I have proposed already to deal 
with this point more fully under the head of the treatment of tinea tonsurans. 

DETAILED DESCRIPTION OF PARASITIC DISEASES. 

I proceed now to describe the mode of origin, the features, the 
course, the causes, and the treatment of the several varieties of 
vegetable parasitic diseases, or the tinese. These diseases are ten 
in number : — 

1. Tinea favosa (commonly called favus). Parasite : achorion 

Schonleinli. 

2. Tinea tonsurans (ordinary ringworm of the scalp). Parasite : 

trichophyton tonsurans. 

3. Tinea kerion (a modification of tinea tonsurans). Parasite : 

same as the last. 

4. Tinea circinata (ordinary ringworm of the body). Including 

Burmese ringworm, Malabar itch, Chinese ringworm, etc. 
Parasite : trichophyton tonsurans. 

5. Tinea sycosis (mentagra, or sycosis parasitica). Parasite : 

microsporon mentagrapnytes. 

6. Tinea decalvans (area, or one form of alopecia). Parasite : 

microsporon Aiidouini. 

7. Tinea versicolor (chloasma, or pityriasis versicolor). Parasite : 

microsporon furfur. 

8. Tinea tarsi. Parasite : trichophyton. 

9. Mycetoma, the madura foot or the fungus foot of India. 

Parasite : chionyphe Casteri. 
10. Onychia parasitica, or onychomycosis. This variety occurs 
as the sole disease, or part of certain of the tinese. 
Eczema marginatum, so-called, I shall describe under the head 
of Tinea circinata. It has been usual to add tinea or plica polonica 
to the above list, but this disease is only a peculiar felting of the 
hair, the result of neglect and uncleanliness, and in connexion 
with which fungi occur accidentally. 

TINEA FAVOSA, OR FAVUS. 

This is a rare form of disease in England ; it is commoner in 
Edinburgh. It commences generally at about seven years of age 
(it may be sooner, it may be later), and is seen among the poorer 
classes of the community. 

General Characters. — It is characterized by the presence of little 
straw or sulphur-coloured crusts, having a peculiarly well-marked 
cup-shaped appearance, called favi, and surrounded by more or less 
redness. The disease commences with the implantation of the spores 
of a fungus just within the follicle, and all that is noticed in the 
early stage is an increased production of epithelial scales ; presently 
a little white sub-epidermic speck becomes visible, which quickly de- 
velops into a" favus." The favus is nothing more than the developed 



430 



TINEA FAVOSA, OE FAVUS. 



fungus about a hair follicle, the latter being in its centre — in fact each 
favus cup is pierced near its centre by a hair. At first the favi are 
but small yellow specks, but they increase in size until they acquire 
a magnitude equal to a split pea or a little larger as regards their 
area. They are roundish (seated upon a depression of the derma), in 
size about -^ to J- inch in diameter, and ^j to ^ inch in depth, concave 
above, convex below, and sometimes marked by concentric lines 
on the upper surface ; they are composed entirely of fungus ele- 
ments — spores, mycelial threads, and granular particles, called 
stroma. They may remain more or less separate the one from the 
other, or they may coalesce in consequence of being thickly 
crowded together, and their individuality is more or less lost in 
the honeycombed appearance presented by the light yellow, irre- 
gular crusted mass which is formed. The terms favus dispersus and 
favus disseminatus have been applied to these two different phases 
of the disease. 

As the fungus grows downwards into the follicle the formative 
apparatus is interfered with, and hence the hair is loosened in the 
follicle, and is at the same time invaded by the parasite, and ren- 
dered brittle, opaque, and thickened. The epithelial scales of the 
surface are likewise invaded by the fungus. If the scalp be en- 
tirely freed from the favi, it is seen to be red and tender, but the 
favi soon re-form. As the disease advances the mass formed by the 
coalesced favi becomes lighter and more brittle, and baldness sets 
in. If the disease be severe the hair follicles are destined, and the 
scalp is reel, irritable, shining, and thinned. The nails often be- 
come invaded by the fungus, and in well-marked cases of disease 
are thickened, rendered opaque, fibrous, and brittle. (See Onychia 
parasitica.) The general health of favus patients is said to be good, 
but in all cases uncleanliness, bad food, bad living, damp dwellings, 
&c, have (some or all) exerted their influence upon such patients. 
There is always a good deal of local itching in favus. The odour of 
favus has been described as like cat's urine, mice, &c. 

The fungus (fig. 66) is the achorion Schonleinii (Link). It 
consists of — (a) spores, generally somewhat oval, j^yq hich in 

diameter, or thereabouts, the largest 
having a double envelope, being either 



Fig. C6. 



o&e 



*£%J* 




free, jointed, or even constricted, 



(b) " filaments which are large or 
branched, more or less tortuous, 
containing generally granules and 
sporules in their interior, and on an 
average goVo mcn m diameter ; (c) 
sporophores or fibres, which are 
short and straight, and bear at their 
extremity spores — generally four, it 
is said — these are not often seen ; (d) 
stroma, which is made up of a number of free but small cells, ex- 
ceedingly minute sometimes." Favus affects the scalp chiefly, 



% 



OK FAVUS. 431 

but it may be seen on the general surface. The fungus invades 
the epithelial scales as well as the hairs. It was discovered by 
Schonlein in 1839, and is .generally regarded as a modified form 
of penicilium. This is a question, however, I need not discuss here. 

The question of the transmission of favus from domesticated 
animals has been very carefully investigated by M. Saint-Cyr,* 
Professor at the Lyons Veterinary School. ITe relates instances 
in which an eruption having all the characters of tinea circinata 
was contracted by inoculation with favus matter, but which in 
some instances subsequently exhibited in parts - the aspects oifavi. 
The source of the favus was diseased rabbits, and also diseased 
mice ; one diseased mouse was found among the clothes and body 
linen of one of the attacked. 

I may take this opportunity of remarking upon one conclusion 
which may be drawn from M. Saint-Cyr's observations — viz., that 
some suitable soil seems to be needed for the free growth of para- 
sitic fungi. M. Saint-Cyr found that though many students 
have been handling, or been in contact with diseased mice and 
rabbits, only a certain few got any disease therefrom. 

In the year 1866 Dr. Purser, of Dublin, wrote to enclose me some fungus taken 
from the paw of a cat affected by favus ; and he remarked that as " several of the 
human members of the family have recently suffered from ordinary ringworm 
of unmistakable character, I thought it unnecessary to employ the microscope. 
They are now nearly well. It was only yesterday that I became aware of the 
disease in the cat." I readily found the fungus, having the characters of achorion. 
As it was interesting that persons were infected from the cat with tinea circinata, 
I wrote for further particulars. Dr. Purser convinced me of the transmission of 
the disease from the cat. Subsequently he sent me some crust taken from an 
inoculated spot on his own arm, which was " spreading at the edges by the for- 
mation of minute vesicles, which leave yellowish crusts, somewhat like those of 
eczema, the centre healing. ... In some of the crusts to-day," Dr. Purser added, 
''lean see very minute sulphur yellow-coloured spots appearing, so that it may 
turn out favus after all." 

I suppose it may very reasonably be doubted whether true tinea circinata is 
produced in these cases. It may be argued that the early stage of favus of the 
general surface of the body, presents external features like tinea cincinata until the 
fungus has had time to fully develop into sulphur-coloured masses, but that 
potentially it is different. This is a point of very little practical importance per se, 
and I shall not argue it out here, since the treatment for the two conditions is 
essentially the same. 

Diagnosis. — Favus might be confounded with impetigo : but 
the latter has a history of discharge ; it has no " cupped crusts ; " 
there is no fungus about it ; and no effects of parasitic growth, 
such as hairs altered in texture, &c. 

Treatment. — This consists in the exhibition of both general and 
local remedies; it is necessary, in the first place, to see that 
favus patients have good food and plenty of fat. Whilst 
cod liver oil and iron are generally indicated, change of air and 
cleanliness are often especially necessary. Locally, the hair should 

* Etude sur la Teigne Faveuse chez les Animaux Domestiques ; Annales de Derm, 
et de Syph., 1869, iv. p. 257. And also the Veterinarian, vol. xlv. No. 531 ; fourth 
series. No. 207, p. 192. In the same number is another article bearing on the same 
question by Mr. Macgillivray. 



432 TINEA TONSURANS. 

be cut short ; the crusts must be removed by soaking with oil, or 
hyposulphite of soda lotion, or, if preferred, sulphurous acid lotion, 
or they may be loosened and in chief part got rid of by poulticing. 
When the scalp is cleansed, the hairs must be extracted, and para- 
siticides applied at once. A number of parasiticides will be 
found in the Formulary (see Nos. 216, 220, &c). A certain portion 
of surface should be cleared each day, the whole head being mean- 
while kept moistened with sulphurous acid lotion. If I want to 
cure a favus case, I epilate and apply the parasiticide myself. But 
it takes time and is troublesome. When the amount of parasite 
has been diminished, as ascertained by the microscope, it is then 
advisable to exclude the air by the free use of unguents, after a 
good application of some parasiticide : the after-baldness must be 
remedied by stimulation, though it is impossible in some cases to 
induce the growth of hair from the fact that the hair papillae have 
been destroyed completely by the inflammatory action set up by 
the fungus. 

TINEA TONSURANS. 

The parasitic disease called tinea tonsurans, and the two next 
about to be described, are in reality essentially the same. In tinea 
tonsurans it is the scalp which is affected, and in tinea circinata it 
is the body that is attacked, and a certain variation of appearance 
is produced in the two cases because the one is entirely covered by 
fully developed hairs, the hairs are texturally altered, and more or 
less destroyed and lost. But if the general surface of the body 
were hairy like the scalp, ordinary ringworm of this part (tinea 
circinata) would present the same features as ringworm of the 
scalp (tinea tonsurans) The other form referred to — viz., tinea 
kerion, is ordinary ringworm of the scalp, in which the hair 
follicles are specially inflamed and pour out a viscid mucus. 

It will be convenient to describe these three forms of tinea under 
separate heads for clinical purposes, but the reader will be good 
enough to remark that they are all produced by the same fungus, 
and that the differences in external aspect are due mainly to dif- 
ferences in accidental concomitants. 

Tinea Tonsurans is the ordinary " ringworm " of the scalp, &c. 
It is rarely seen except in children — in fact I have, I believe, never 
seen it in the adult. It is, like favus, contagious. It does not 
appear to be attended by any marked ill-health, though it is fre- 
quent in lymphatic subjects. It generally consists of little circular 
patches, varying in size from one-half to several inches in diameter, 
covered over by very fine whitish meal-like scales, and the hairs of 
which look dry, withered, and as if nibbled off at a distance of aline 
and a half from the scalp. In the first instance a fungus is im- 
bedded in the under surface of the epithelium, just within the 
follicle. It finds its way into the follicle more deeply, and excites 
some little irritation and hyperproduction of epithelial cells from 



TINEA TONSURANS. 433 

the hypersemia induced, as seen by the microscope in the early stage, 
so that the hair is surrounded by an unusual mass of epithelial and 
blastematous matter. The fungus presently gets down to the 
formative papilla, thence into the hair itself, and is carried up with 
the growing parts into the hair, which becomes in consequence 
changed, as before described — i.e., opaque and brittle. In this early 
stage the hair altered in texture is bent or twisted just above the 
point of its emergence from the follicle, and it is at this place that 
the hair presently, still more changed by the developing of fungus, 
breaks off, producing a " nibbled off " appearance. If an attempt 
is made to pull the hairs out they break off. At this time the ori- 
fices of the follicles appear to be fringed round with little " mica- 
ceous " scales, and the surface of the diseased patch is the seat of 
the furfuraceous desquamation, composed of meal-like scales be- 
fore noticed. As may be readily understood if it be remembered 
that there is in the follicles a certain amount of effusion as well as 
of parasite and of epithelial cell collections, the whole patch be- 
comes slightly elevated, and the individual hair follicles more promi- 
nent than in health. The scalp may be diseased in one spot, in 
several places, or over its whole extent. Oftentimes a little erythe- 
matous ring bounds the circumference of the diseased patches. If a 
diseased hair be extracted and examined, it will be noticed to be 
swollen, perhaps bulged here and there, of dark colour or opaque, 
with its fibres more or less separated by collections of conidia, which 
become distinctly visible on the addition of a little liquor potassae ; in 
other cases the diffusion of conidia is pretty general. As in f avus, 
if any mycelial threads are present they mostly run parallel to the 
fibres of the hair, and not transversely. Figure 67 is a very 
good representation of the fungus found in this disease. The my- 
celium is shown in fig. 70. The fungus of tinea tonsurans is termed 
trichophyton tonsurans (Malmsten) or achorion Lebertii ; the spores 
are most numerous ; they are round, '003 to '007 mm. long, by 
•003 to *004 mm. broad (-goVo to -3-^ inch), nucleated, oftentimes 
constricted, and exhibit a great uniformity in size in the same sub- 
ject: they are very plentiful in the root of the hair. The fila- 
ments are articulated, somewhat undulated, and possess granules 
in their interior. They are few in number. The fungus invades 
not only the hair but the epithelial scales. The conidia are some- 
times so thickly crowded together en masse that it is difficult to see 
them, nor do they appear distinct until the mass is separated out. 
Fungi, I think, are often overlooked from taking too thick a mass 
of material for microscopic examination. 

As the result of tinea tonsurans more or less baldness may occur, 
but this is a temporary affair. A certain amount of itching is fre- 
quently present in the disease. Tinea circinata, or ringworm . of 
the surface, very commonly occurs in connexion with tinea tonsu- 
rans. In a public school near London in which ringworm existed 
as an epidemic, I found that distinct tinea circinata existed or 
28 



434 TINEA TONSURANS. 

had been present in 55 ont of 121 children who were affected with 
tinea tonsurans. This will give some idea of the frequency with 
which the two local varieties of common ringworm co-exist. 

There is another fact worth mentioning in relation to the iden- 
tity of tinea tonsurans (scalp) and tinea circinata (body). It is 
this, that a patch of tinea circinata, say of the face, contiguous to 
hairy parts, may, by enlargement, encroach upon these latter, and 

Fig. 67. 




in that case the hairs become implicated and tinea tonsurans is 
produced. Illustrations of this fact I have often noticed not only 
where ringworm travels from the forehead to the scalp, but also 
when the eyebrows and contiguous parts are affected by ring- 
worm. A well-marked case of this kind came under my notice 
a little time since (1871), which furnished the accompanying illus- 
trations : fig. 68 representing the fungus seen in the scales, and in a 
hair taken from a furfuraceous patch of tinea circinata, fig. 
69, the fungus attacking one of the hairs of the inner half of the 
eyebrows, which were brittle, broken off, and thickened, as in tinea 
tonsurans ; in fact, this half of the eyebrow presented all the aspects 
of tinea tonsurans. In this case tinea tonsurans of the scalp was 
also present. It follows from the fact that tinea circinata and tinea 
tonsurans differ only as regards seat, that the former can, by con- 
tact, give rise to the latter. This must be remembered in reference 
to the prevention of ringworm amongst the healthy. But I shall 
speak particularly of this matter in dealing with ringworm as it 
occurs in schools. 



TINEA TONSURANS. 



435 



Fig. 68. 




Tinea tonsurans is more prevalent at some than at other times. 
It may prevail in schools and public institutions as an epidemic, but 
as there are certain special considerations to be mentioned when 
it so occurs, I propose to 
devote a separate section 
to the subject of " Ring- 
worm in Schools " after 
having described the di- 
agnosis and treatment of 
tinea tonsurans, p. 442. 

Diagnosis. — Tinea ton- 
surans in an early stage 
bears no resemblance to 
any other disease. Over 
a small circular spot the 
hairs look dry and with- 
ered. They are bent just 
above their point of emer- 
gence from the follicle, 
and there break off, and 
the presence of these 
broken off hairs is 
characteristic. No other 
disease, save a parasitic 
one, will produce this. 
Whenever, then, on the 
scalp, a circular patch of 
disease occurs, which is 
somewhat scaly,and there 
are short broken off hairs 
studding its surface, the 
microscope should al- 
ways and at once be used, 
and will give plenty of 
evidence of the presence 
of a fungus. 

Treatment. — It is ne- 
cessary in dealing with 
the treatment to recollect 
that three things are re- 
quired of the practi- 
tioner. 1. To alter, if 
possible, the soil so as to 
render it less suitable to . 
the growth Of the para- A hair irom a patch of T. tonsuran ; of the eyebrow 

site ; 2, to destroy the parasite ; and 3, to remedy th 3 consequences 
of the attack of the parasite. Of course, in slight cases, and where 
the fungus has not penetrated deeply into the f jllicle, it is easy 



Broken off hairs and epithelial masses from a 
patch of " furfuraceous " ringworm of the forehead, 
involving the eyebrows, the inner part of eyebrows 
being tonsui\ nt. T. tonsurans of the head co-ex- 
isted. 

Fig. 69. 




436 TINEA TONSUEANS. 

to destroy the parasite by local remedies at once, and to put an end 
to the disease, bnt I am now speaking of what is required from the 
medical man in the majority of cases of tinea tonsurans. 

First, as regards the soil. Most instances of ringworm occur 
in children who possess the lymphatic temperament, many in 
those who are strumous, or who are at least thin, fair, and pallid. 
Even in the instance of dark-complexioned children, some of the 
evidences of the lymphatic temperament are frequently present. 
If inquiry be made, in a mass of instances, according to my experi- 
ence, children attacked by ringworm will be found to have been 
in the habit of taking very little fatty matter, or, if taking it, to 
have assimilated it very badly. Mothers and nurses, as I hare 
pointed out,* will, in reply to questioning, 

Affirm that this or that child will never touch a bit of fat, and the frequency 
with which the fat of meat is scrupulously avoided by many children suffering 
from severe ringworm has long struck me as a remarkable fact. But supposing 
children do eat fat, it is often not assimilated, for the stools are pale or clay-coloured, 
the digestive act performed with difficulty or discomfort, and the tongue is pale, the 
urine loaded, and headache is frequent, and there are symptoms that point to an 
inactive liver and scanty biliary secretion, in connexion with which deficient absorp- 
tion of fat from the intestinal tract must be associated. As a point of practical im- 
portance, I find it of the greatest service to recognize — over and above the propriety 
of removing anaemia, debility, and other causes of weak health, which necessarily 
favour the increase of tinea tonsurans — the peculiar necessity for exhibiting to 
children attacked by ringworm a large amount of fatty matter, if not in the food, 
at least in the shape of cod-liver oil, and of preparing the way for the due assimi- 
lation of the oil by removing dyspepsial conditions and hepatic torpor. The con- 
joint exhibition of alkalies and bitter tonics is, in relation to the latter circumstances, 
most useful. It is important to review the general nature of the diet, and to 
increase its meat and milk items when deficient in amount. Plenty of fresh air, 
extreme cleanliness, and the other hygienics are also requisite. If there be con- 
joined to ringworm a tendency to or the presence of actual eruption, and the latter 
be scaly, or the attacked individual present the nervous temperament, arsenic, and 
iron in combination may be given, but I still prefer the cod-liver oil. I can only 
repeat that cod-liver oil often fails to do good, or is tardy in so acting, if the prac- 
titioner omit to put the digestive organs into due working order so as to assimilate 
it. The removal of anaemia which obstinately persists in some chronic cases of tinea 
tonsurans is to be accomplished no less by fresh air and liberal diet than sometimes 
by iron. There is clearly occasionally a condition of nutrition very favourable to 
the rapid development of the mycelial threads of the trichophyton vegetation which 
is negatived by a course of arsenic. 

The second object in view is to destroy the parasite. But in 
order that the remedies employed to kill the fungus and called 
parasiticides may be used with success, certain preliminary measures 
must be taken. It is necessary, whenever a case of ringworm 
comes under treatment, that the treater should obtain a clear 
view of the whole extent of every patch of disease. The hair 
should be cut off, with scissors, close to the scalp over the actual 
diseased area of patches, and for some distance round them, and 
if the disease is of old standing, or there are many separate places 
scattered about, it is best to cut all the hair off, leaving just a 

* Practitioner, March, 1870, On the Treatment of Ringworms. 



TINEA TONSURANS. 437 

band in front to show from under the cap. Shaving makes the 
part tender, and causes abrasions that are quickly irritated by 
parasiticides. Even when the places of disease are small and 
recent it is better to cut off the hair. Frequently fresh spots 
spring up around the old ones, and a " clear road " and "no 
favour" should be the doctor's motto on every occasion. It is 
necessary to apply the remedies for some distance beyond the 
actual area of the diseased patches to check the disease in its 
earliest state of spreading. Having cut short the hair, the prac- 
titioner is enabled to see the contrast at once between the upright 
and shining hairs of health with their connected healthy scalp, 
and the dull, brittle, twisted and broken-off hairs and the dis- 
coloured scaly or inflamed scalp of disease. 

The next thing to be done is to get away as much of the rem- 
nants of the diseased hairs and attached and contained fungus as 
possible. It is very essential that this step should be taken in 
bad cases of tinea. The removal of the bulk of diseased hairs may 
be accomplished by epilation or the extraction of the hairs by 
means of forceps. This statement is in contradiction to the 
general teaching of authorities on this subject, but it is neverthe- 
less true. Epilation involves trouble and takes time, and many 
are glad to shirk it altogether. I employ a pair of small forceps 
with closely-fitting broad blades, and " nibble " as it were at the 
diseased hairs rapidly, pulling freely at them at the same time. 
A few minutes will bring away the mass of those portions of the 
diseased hairs which are above the follicle over an area of an inch 
or so, and also many of the follicular portions of hairs likewise. 
It is perfectly true that most of the hairs are brittle, and break 
away when an attempt is made to pull them out, but still for all 
that a great quantity of fungus is got away by epilation, which 
also makes the action of parasiticides more effective. If the hairs 
are not very loose, and epilation gives pain, it may be advisable 
to blister the diseased patch once or more, or to use the oil of 
cade freely to it ; by these means the hairs are considerably 
loosened. Of course much of the fungus will be left behind with 
portions of the hairs and their roots in the follicle, and as the 
hairs grow up they must be removed again and again by epilation. 
In some cases the hairs in the follicles become detached from the 
hair papillae, and remain more or less immovable on the follicle 
as so much dead matter upon which the fungi freely luxuriate. 
Such hairs appear as swollen dark stubs studding the surface of 
old standing patches of disease. These stubs should always be 
extracted. They are always loaded with conidia of large size, and 
are as so many laboratories, capable of disseminating germs of 
disease far and wide. As to how long or how many times epila- 
tion is to be repeated, I will only say that the microscope and the 
general aspect of the disease must guide us. If the hairs which 
spring up over a patch look diseased ; if they are brittle and 



438 TINEA TONSUEANS. 

loaded with conidia ; if the formation of the root-sheath of the hair 
is prevented and the root itself be invaded by the fungus, then it 
is requisite to epilate and use parasiticides again and again. The 
reader will understand that epilation may not be required in the 
slightest cases of tinea. 

In all cases the head should be well washed with mild soap two 
or three times a week. 

Having fairly exposed all diseased spots, and got bodily away 
as much of the diseased hair and fungus as possible, the next 
duty of the practitioner is to apply certain remedies that destroy 
fungi, and to keep up the action of these upon the scalp until the 
disease goes. Epilation and the use of parasiticides should be 
employed more or less in conjunction throughout the whole 
course of the disease. Now there are two classes of parasiticides 
(see Formulae Nos. 215-233), viz., those which blister (vesicating 
parasiticides), and those which are of milder action (milder para- 
siticides). The former are used — hut only to small areas — to make 
a decided impression upon the disease at the commencement of 
active treatment, and also in severe cases ; the latter are used to 
keep up parasiticide action generally after the use of the more 
powerful parasiticides, but they suffice in some instances alone for 
mild cases of tinea. 

In well marked instances of disease, the practitioner having, 
when necessary, adopted the preliminary preparatory measures 
before described, may use ordinary vesicating fluid, brushing it 
lightly over the patch ; and when it begins to smart, drying it off, 
if necessary, with blotting paper. Strong acetic acid may be 
used, or Coster's paint (Formula 25). 

Light haired and fair children, ill nourished, and strumous 
subjects do not bear blistering at all well. When vesicating para- 
siticides are used, they should be handled with care. I have said 
they are to be lightly brushed over the diseased patches, and 
blotted off when they begin to smart, but they should be used 
sparingly to an area of an inch or so, and in one or at most two 
or three smallish places at any one time. They should be used 
also by the practitioner himself. If much irritation, pain, or 
swelling follows, a poultice may be applied for an hour or two. 
The parasiticide is to be reapplied if diseased hairs still remain 
plugging the follicle, and are distinctly visible to the naked eye, 
twice or three times to the same patch, but at proper intervals. 
But in no c#se till the irritative effect of the former vesication 
has subsided, and if the diseased area is raw or tender, it should not 
be treated with the stronger parasiticides. Strong acetic acid or 
Coster's paste may be used every fourth, fifth, or sixth day. The 
latter " cakes " on ; and when the dark mass which results begins 
to flake off, the head may be well washed, and the flakes helped to 
fall off, and the paste reapplied. It should be painted on with a 
brush, and blotted off if it smarts very much. I often make 



TINEA TONSUKANS. 439 

eight or nine applications at intervals of three, four, or five days, 
until in fact I get rid of all hairs visible to the naked eye which 
look diseased. I formerly used an alcoholic solution of bichloride 
of mercury, and liked it very well, but it is rather a painful appli- 
cation, and Coster's paint or blistering fluid is better. 

During the time that the head is being treated with the stronger 
parasiticides, it is well to apply some of the milder ones night and 
morning. When acetic acid is employed, the head, if extensively 
affected, may be kept wet with sulphurous acid lotion (one part to 
six or four of water). But this brings me to the consideration of the 
use of the weaker or the ordinary parasiticides. These are to be 
prescribed in slight cases without preparatory treatment, or in severe 
and extensive cases when the "worst of the disease" has been 
"got under" by the more powerful measures of epilation and 
vesication, &c. The object in their use is to bring them into 
contact with the parasitic elements, and this in the slighter forms 
of disease is readily done by friction, or by using, as a medium for 
their exhibition, some fluid that penetrates the tissues, such as 
spirit. 

Taking the general run of cases, I think the lesson to be learnt in 
regard to the employment of parasiticides is the value of friction, 
with remedies of a moderate strength. I believe this is preferable 
to the application of strong and active remedies ; at least I have seen 
many bad results from the too long and too frequent use of strong 
and perhaps vesicating parasiticides. The power to say with success 
when a strong and when a weaker parasiticide should be used in any 
given case in the first instance, or during any part of the course 
of ringworm, is to be obtained by microscopic examination. If 
the fungus is plentiful and luxuriant, and the disease spreading, 
potent measures are called for at all times. I do not think so 
much stress need be laid upon the particular (milder) parasiticide 
selected for general use. Formulae 229, 231, 232 are very good 
ones. Some prefer sulphurous acid lotion throughout. If it be 
good and kept constantly applied it is very efficacious. But it is 
difficult to get it properly made, and more difficult to get nurses 
and mothers to keep lint wetted with it, applied to the head, and 
a layer of oil silk over the whole, without which it becomes an 
almost valueless remedy. 

Now if the disease is obstinate, or becomes, when all seems 
going on well, worse, it is necessary to use some strong parasiticide 
from time to time. As I said before, the microscope must be had 
recourse to, as the guide to the use of remedies. The presence of 
actively growing fungus calls for active treatment. 

The indications that the means adopted for the cure of the 
disease are operating beneficially are significant and readily per- 
ceived. In the first place, when the case is approaching cure, the 
number of hairs that become opaque and brittle lessen in amount, 
the scalp looks healthier. The new hairs that appear grow out in a 



MO 



TINEA TONSURANS. 



straighter and more natural direction : they are not dry, shrivelled 
looking, twisted in different directions. They are not brittle, bnt 
they are more firmly attached in the follicle. If the microscope 
be used, the root is seen to be properly forming, and more and 
more free from fungns elements ; and what is of great consequence 
the root sheaths are beginning to re-form, a sure sign of good 
progress. But still the practitioner must be on the watch. If 
notwithstanding the tendency to the approximation of a healthy 
condition, the hairs are more or less loose in the follicles, and if 
there are in addition short dark stubs, the case must be carefully 
watched. The accompanying representation affords an illustration 
of the mischief which may lurk under a seeming state of health. 
The figure (fig. 70) represents the appearance seen in the root of 

Fig. 70. 




a young growing hair, which to all appearance was healthy to the 
naked eye, but it came away readily on being pulled out. The fact 
being that the shaft was healthy, but the young growing root had 
become infected by the fungus, some of which must have got 
access to the follicle from dark " stub " left behind in an adjoining 
follicle. I think it worth giving, as it illustrates a very practical 
point. Such a state necessitates the liberal use of a mild parasi- 
ticide for some time if its use has been omitted. Sometimes the 
scalp gets puffy ; the application of tincture of iodine every other 
day does good in these instances. 

In some old standing cases of tinea tonsurans, the disease 
becomes reduced to two or three smallish spots about the crown 



TINEA TONSURANS. 441 

of the head, and may be felt and seen, according to the nurse's or 
parent's account, as little " knotty," or " scurfy " places. On 
examination a little erythematous patch is detected the size of a 
threepenny piece or more, scaly, or slightly crusted, perhaps tender, 
and it may be, showing one or more pustular heads, and possibly 
in some cases, short broken-off hairs containing the fungus ele- 
ments ; if so, it is necessary to get away all the " stubs " or hair 
stumps, and to use a little weak mercurial or tar ointment for 
awhile, but the hair stumps are the cause of mischief in such 
instances. 

Overtreated Cases. — Cases of ringworm may not only be treated 
too little, but too much — that is, overtreated. I am constantly in 
the habit of seeing cases to which have been used ointments " got 
at the chemists," or recommended perhaps by some friend, and 
in which the hair follicles suppurate, the tissues of the diseased 
area being swollen, puffy, in some cases boggy, or actually dis- 
charging pus from subcutaneous formation of pus. The whole patch 
is also in many instances entirely devoid of hair, though red 
and tender. A hair here and there may be dragged out from a 
considerable depth as though it had been contained in a follicle 
half an inch or so long. I know at once what has happened when 
these cases come into the out-patients' room. Mostly the parasite 
has been destroyed, but the papilla has not been irrevocably 
injured, and so the hair re-forms. The hair is at first, before its 
connexion with the papilla has been loosened, tied down to the 
bottom of the follicle, whilst the follicle is elongated by the in- 
flammatory swelling and effusion into the tissues, and hence the 
hair being fixed below, becomes imbedded in the elongated and 
deepened follicle, and can, as I have said, be pulled out as it were 
from a great depth. These cases require to be left alone or simply 
soothed. 

A similar condition, but not so intense, is sometimes induced 
by the too long continued use of ordinary parasiticides, and as 
happens sometimes in scabies, the original disease may be really 
cured, and a new one set up. In fact, folliculitis is set up, and 
the first bad indication is the appearance of little pustular heads 
studding the surface of a patch of disease that appeared to be 
making satisfactory progress towards cure. If the microscope be 
used, it will be noticed that little or no fungus is to be detected, 
the hair is well formed, the root sheaths also ; but there is much 
inflammatory matter surrounding the hair — that is to say, there 
is evidence of a return to a healthy state of hair, but also the presence 
of inflammation without any fungus to explain it. I desire to 
impress upon my readers the paramount necessity of a constant 
appeal to microscopic appearances as the best guide to the effects 
produced by the use of parasiticides. It not unfrequently happens 
that the use of parasiticides is either not sufficiently pushed where 
the disease is making rapid progress, or is employed in cases where 



442 



RINGWOEM EN" SCHOOLS. 



the results of the irritative action of parasiticides in the follicles 
are mistaken for a continuance or aggravation of the disease. 

The third indication in the treatment of parasitic disease to 
remove the effects of the ravages of the fungus, is soon dealt with. 
Eczema and pityriasis are to be dealt with upon ordinary principles, 
and with ordinary measures. The regrowth of the hair can be 
accelerated by the use of some stimulant wash, such as is useful 
for alopecia. 

It is also requisite that measures should be taken during treat- 
ment of ringworm for preventing the transportation of the disease 
from spot to spot on the same head by the dissemination of conidia 
and spore tubes. This is effected by observing scrupulous cleanli- 
ness, by using parasiticides to the whole scalp if the disease is 
severe, and also by oiliug the scalp. The collection of scales 
must likewise be prevented. 

RINGWORM IN SCHOOLS.* 

• 

Troublesome and disappointing as the management of ringworm 
in ordinary practice is, it is infinitely more so in schools and 
public institutions. The consequences of error in regard to ring- 
worm cases in public institutions are in some points of much 
more serious account. A mistake, for example, in deciding when 
complete recovery is established is not only often most injurious 
to the reputation of the practitioner, and of course disappointing 
to parents, but cruel to the principal of the school concerned, 
whom it involves in great annoyance and sometimes serious 
pecuniary loss. One of the chief questions upon which a decision 
is requested is the fitness or unfitness of those who are supposed 
to be convalescent to go back to school, and to remingle with 
their playmates. 

The whole question of ringworm in public institutions has 
recently been prominently forced upon my attention in the case 
of a remarkable outbreak of the disease, comprising some 300 
cases in all, in a public institution near London. I was requested 
to investigate and report upon the epidemic. With the facts 
fresh in my mind I shall, perhaps, be doing good service to my 
readers if I reproduce some special remarks on the subject of ring- 
worm in schools, which I recently penned elsewhere, under the 
heads of — 

1. Its origin and dissemination. 

2. The treatment of the disease when introduced, as regards 
(a) the actually diseased ; (b) the surroundings and belongings of 
the attacked. 

3. The preventive treatment — as regards (a) its re-importation 
through the apparently convalescent ; (b) its rekindling from 
other causes. 

* Reprinted from the Lancet, Jan., 1872. 



RINGWORM IN SCHOOLS. 



443 



I. Origin and Dissemination. — Origin. Firstly, I do not understand that a 
school is properly managed unless every child admitted is shown to be free from 
ringworm of the head (tinea tonsurans) and ringworm of the body (tinea circinata), 
either as certified by a medical practitioner, or by a careful examination at the 
time of admission by some competent person. A matron or good nurse can have 
no difficulty in preventing the introduction of ringworm into the school under her 
management as the rule. Every child with ringworm (tinea tonsurans) has cer- 
tain l ' scurfy patches " or spots where the hair looks shrivelled or unhealthy. 
Such appearances and red scurfy patches are on the body readily detected by any 
one who has a pair of eyes, and they should suffice to excite suspicion and lead, 
to medical examination. Secondly, every week at least, a careful inspection of heads 
should be made in schools. The heads of girls should especially be searched on 
account of their long hair. In this way the earliest signs of disease must be de- 
tected. Ringworm of the body (tinea circinata) should be recognised more decidedly 
than it is as the frequent source from whence is derived the fungus that causes 
ringworm of the head, and should be dealt with accordingly. 

Dissemination. — Once introduced into schools, ringworm is spread in several 
ways ; (a) By neglect, of course ; (b) by actual contact of the healthy with the 
diseased ; (c) by the use in common of towels and brushes by the diseased and 
healthy ; (d) by theair of the institution, which, under certain circumstances, is 
loaded with the germs of the fungus — trichophyton tonsurans. 

I am particularly anxious to call special attention to the last point. When I 
came to collect the dust deposited from the air in the wards of the institution in 
which the outbreak of ringworm before referred to occurred, I found that it con- 
tained fungus elements in abundance. This observation I believe to be a novel one. 
The achorion has been detected in the 

air passing over the heads of children FlG. 71. 

affected with f avus, I know ; but I 
speak of the existence of the tricho- 
phyton in the air when no artificial 
means have been adopted to dissemi- 
nate it there. Fig. 71 gives the ap- 
pearances seen, with a one-fifth inch 
object-glass at four P.M., in the dust 
which had collected upon a slide 
between that time on a certain day 
and the evenirg before. I need not 
say care was taken to avoid all fallacies. 
It will be noticed that epithelial scales 
were found in the dust, and that is 
why I give the sketch on next page, 
and it is only a sketch. No doubt 
the scratching of diseased places 
practised by the patients explains 
the presence of those several ele- 
ments in the dust. I presume it was 
the fact of so many children being 
diseased — I saw 121 together at the 

time of my visit — at one and the same time that gave rise to such a plenti- 
ful supply of fungus ; for I imagine that we should have a difficulty in detecting 
the fungus in the dust of a room where only a few cases of ringworm were present. 
I cannot doubt that where ringworm of the body (tinea circinata) only is present, 
particles of cuticle and fungus may be thrown off by scratching, and so give rise 
by the development of germs which fall on the head, to tinea tonsurans. In all 
cases therefore an endeavour should be made to neutralize this source of dissemi- 
nation by particularly enforcing the isolation of the infected, including those who 
suffer only from ringworm of the body, and to disinfect the air where there is reason 
to think fungus germs exist in it. 

II. Treatment. — (a) As regards the actually diseased.— strict isolation is the 
first thing to accomplish. I will only say on this point that cases of ringworm 
of the body must be isolated. I think this is of essential importance in the case 
of schools. It is not, however, thought of any moment as the rule. Where a 
number of cases occur, it is better to separate instances of very bad and extensive 
disease from slight new cases and convalescents, for the simple reason that active 




444 



RINGWORM IN SCHOOLS. 



treatment may at once annihilate the disease in the former, and in the new cases 
and convalescents fresh implantations over the, in the main, healthy area of the 
scalp may be taking place from contact with bad cases of tinea. I would, of course, 
only adopt this plan where the cases of disease are very numerous — say thirty, forty, 
and fifty or more. 

There are, next, certain general considerations to be taken account of. Atten- 
tion to the dietary is one ; for the underfed, and ill-nourished, and ill-kept furnish 
the most appropriate nidus for ringworm. All deficiency in meat should be recti- 
fied, and in case the attacked or the non-infected look sickly or pallid, the allow- 
ance of meat and fresh vegetables should be increased and supplemented by iron 
and cod-liver oil. So, again, the cubic space alloted to each child should be ample, 
ventilation free, and cleanliness enforced with exceptional strictness. One word 
more as regards the general health of children. If, with a rigorous system of in- 
spection in constant operation, many cases rapidly appear, and, in spite of hygienic 
measures, spread, the children furnish clearly a very suitable soil, and the dietary 



Fig. 72. 




of the children should be looked to. If ringworm becomes epidemic, with a bad 
system of inspection, it implies simply neglect, of course. Here isolation is the main 
thing needed to protect the healthy, and not feeding up. 

The treatment is essentially the same as that already described as suited to 
ordinary cases of ringworm. In all cases in schools the hair should be cut short, 
close to the scalp. 

(b) As regards the surroundings and belongings of the attacked. — It is scarcely 
necessary to do more than refer to the necessity of thoroughly cleansing the 
brushes, combs, and towels of the diseased, seeing that these are not used in 
common by the healthy and the infected. Towels should be well boiled. To one 
novel point I must direct special attention. It is the disinfection of the air of the 
wards in which a large number of cases of ringworm have been. My recent ob- 
servations show that the fungus germs are floating in the air, and though I had 
no experience to go upon, because the observation is a novel one, yet I have no 
hesitation in saying that the air of the wards should be disinfected by burning 
sulphur if, after complete isolation has been practised where many cases of ring- 
worm have occurred, other instances of disease still continue to appear amongst 
the previously healthy. 



TINEA KEEION. 445 

m. The Pretention of new Outbreaks. — (a) As regards the reimportation by 
tlwse apparently convalescent. — No more puzzling problem is presented to the 
practitioner than that of saying when a child "is well of ringworm," and "fit to 
go back to school. " I err on the side of caution if there is the least doubt, and 
advise that the same course be taken by others. "When a child is well — that is to 
say, incapable of reimporting or redisseminating the disease amongst his fellows — 
there will be present certain naked eye characters and microscopic appearances. 
The hair will be growing vigorously and naturally on the original sites of the 
disease ; there will be do scurfiness, no broken-off hairs, and the structure of the 
hair and its sheaths will be properly developed and free from fungus elements. If 
the hair is dull and dry, suspicion should be excited ; and if the suspected surface 
is studded over with short broken-off hairs {readily overlooked), there is still disease 
present. The fungus will be formed in abundance in the short broken-off hairs. 
As a rough guide, this is the best. A child any portion of whose scalp is studded 
with the little dark points of short broken-off hairs, should be regarded as unfit to 
go amongst his fellows. This is the rule I observed. But no one can arrive at a 
really safe conclusion in some cases without a microscopical examination. If the 
root is well formed and the hair sheaths likewise ; if fenestrated membrane and 
root sheath can be seen, and no fungus detected, then all is right. Of course, 
fungus in any abundance is at once discovered. The doubtful cases are those in 
which the root seems healthy, but the shaft of the pulled out hair is observed to 
be surrounded at its follicular portion above the root with epithelial and exudation 
matter. This may be an indication that irritation is being set up by the remedies, 
the ringworm itself being well. I see many cases of this kind, and in them the 
roots and surrounding structures, and hair-shaft, are healthily formed, whilst no 
fungus elements are to be detected in the material surrounding the hair. The scalp 
in these cases is tender, more or less swollen, and reddened, the hair at the same 
time growing well and vigorously. Perhaps the plainest and easiest guide to disease 
still existing is the presence of short broken-off hairs. 

(b) Rekindling of the disease from special causes. — In order that ringworm may 
not " break out afresh " in schools, the non-infected must observe all those directions 
which were referred to under the head of " dissemination of the disease." Espe- 
cially it is important to keep heads perfectly clean by frequent washings, and to 
keep them fairly greased or oiled. To this latter point I attach much importance. 

This, in short, is a sketch of the means to be followed in managing ringworm in 
schools. There are those who think the use of a weak parasiticide to the healthy 
is advisable. Well, there can be no objection to sponging the heads, even daily, of 
the healthy with diluted sulphurous acid, one part to six of water, or, better, with 
diluted acetic acid, one part to four or six of water. 

TINEA KERIOX. 

This phase of ringworm generally commences like ordinary tinea 
tonsurans, and the fungus is the trichophyton. The glands of the 
skin become involved with the hair follicles, and ponr out a mucoid 
secretion. It was to this form of disease that Celsns gave the 
term kerion in describing it in his fifth book. 

The disease, which consists of large or several small patches, 
may commence suddenly, with more or less loss of hair. The 
hair breaks off from over a circular area of greater or less extent, 
when general swelling of the textures speedily follows. These 
swellings are tender, and they also look uneven and feel boggy 
without there being pus present, and after a while a number of 
apparent openings give exit to a viscid discharge. They stud the 
surface of the patch and are inflamed follicles. The hairs are 
loosened and diseased as in tinea tonsurans. There is, how- 
ever, no true suppuration. The fluid discharge reminds one 
of the viscid juice of the mistletoe berry. The glands of the neck 



4:46 TINEA. KERION. 

are sometimes enlarged, and very tender; they may even sup- 
purate. 

The characters of kerion are therefore : (a) general prominence 
of the patch ; (b) its perforation with foramina — i.e., the mouths of 
the hair follicles ; (c) the outpouring of a mucoid fluid ; (d) the 
non-suppuration of the swelling; (e) the looseness of the hairs; 
(f) the after baldness ; (g) the presence of a fungus in the hairs 
and follicles. 

The most careful inquiry has failed, in my cases, to detect the 
evidence of the application of irritants as a cause of the unusual 
swelling and exudation. The peculiar sticky secretion is albumi- 
nous lymph. It seems to me that the fungus causes inflammation 
of the follicular sheath, that a large amount of irritation is set 
up, the glands of the hair-follicles are involved, and mucoid fluid 
is poured out. This condition may run on to threatened suppura- 
tion. In plica polonica a similar kind of exudation is poured out 
into the hair-follicle, and infiltrates even the hair-shaft. 

I regard this kerion so accurately depicted as to external 
features by Celsus, as nothing more or less than tinea tonsurans 
which has become complicated by irritation, swelling and promi- 
nence of the hair follicles and the attached glands, detachment of 
their follicular sheaths, and exudation of albuminous lymph. It 
is a wonder that this is not a more frequent condition in tinea 
tonsurans. It is not unlike the state of scalp produced by the 
application of irritants to tinea tonsurans before described under 
the head of that disease, only in that condition the follicle is 
choked with inflammatory pus products, and in kerion the secre- 
tion is mucoid, whilst the hair-sheaths come away bodily, as it 
were ; but, as I have said, I cannot trace the disease to such a 
cause as irritation. 

I have long been acquainted, and indeed was the first to de- 
monstrate the presence of the trichophyton in the disease, and I 
have been surprised at the amount of fungus present in some 
instances. Mr. Wilson notices that it was complicated by tinea 
circinata in two out of fourteen cases, and tinea tonsurans in one 
case ; whilst a brother of one of the patients had the former affec- 
tion, and a sister of another the latter. In one instance, kerion 
was observed to develop out of tinea tonsurans. 

This tinea kerion has been made the subject of an excellent 
description qitoad naked eye appearances by Dr. Dubini,* who 
styled it Yespajus del Capillizio {i.e. Wasp's Nest of the hairy 
scalp). Dubini remarks that he has not found it noticed in 
dermatological works, but he has been anticipated in his descrip- 
tion of it by Celsus, by Wilson, and myself ; and he fails, more- 
over, to recognise its parasitic nature. 

The plan of Treatment that suggests itself to the mind in the 

* G-iornale Italiano delle Malattie Veneree e delle Malattie della Pelle, 1866, p. 7. 



TINEA CIECTNATA. 447 

first instance would seem to be the employment of decidedly 
emollient remedies — poultices and soothing applications — to sub- 
due the inflammation. But this I believe to be an unsound plan ; 
for as in scabies complicated by many and various eruptions it is 
proper to treat the scabies, and attempt to kill the acarus at 
all hazards, so in kerion it is right to destroy fungus as the first 
step towards a cure. The plan is to pull out all the hairs. This 
will generally remove the greater portion of the fungus, for the 
hair and follicular lining come away together, and necessarily the 
conidia imbedded therein. Then mild parasiticides may be applied, 
ex., weak bichloride of mercury solution, or carbonic acid lotion, 
and the disease will rapidly mend. 

Apparent severe inflammatory action should not deter us from 
destroying the true cause of mischief — the fungus. These cases 
are no new acquaintances of mine, and therefore I speak with 
some confidence. 

Finally, it is important to add one practical remark. I have 
seen these cases of kerion mistaken for subcutaneous abscess 
(nothing more likely and nothing to be more avoided), and 
accordingly the swelling has been opened by the lancet, not, how- 
ever, with any good result, for troublesome abscess has followed 
the procedure, with suppuration induced by the admission of air 
into the tissues. 

TINEA CIRCINATA (TINEA CORPOEIS), OR RINGWORM OF THE 
GENERAL SURFACE. 

General remarks. — I have already, under the head of tinea ton- 
surans, stated that tinea circinata differs in reality from that 
disease only on account of its occurring on non-hairy parts, and 
have shown that when tinea circinata travels on to hairy from 
non-hairy parts, it assumes the characters of tinea tonsurans. I 
am about to describe it, however, under a separate head, because 
its actual naked-eye features are so distinct and peculiar ; it lacks 
the appearances produced by the diseased hairs of tinea ton- 
surans. 

When a fungus becomes implanted upon the surface of the body it excites more 
or less irritation. This is followed by hyperemia and effusion of serosity, which 
may produce vesiculation. If the effusion be slight in amount, scarcely so much as 
uplifting of the cuticle occurs, but only some slight hyperaemia, and consequent 
desquamation : so there may result an herpetic looking patch, or merely a red rough 
desquamating surface. If the irritation be very great, the characters of herpes 
may be more than usually marked, or even those of eczema may be presented by 
the disease. In other words, the fungus will excite a varying degree of localized 
inflammation, and the aspect of the disease will vary accordingly. Further, some 
persons furnish a very suitable soil for parasitic growth, with or without a disposi- 
tion to eczema or other eruptions. A little fungus may excite a good deal of 
change, so that the amount of fungus and eruption bear no necessary proportion. 

But there are other considerations to be taken into account in attempting to 
understand the characters of tinea circinata. 

When the fungus grows it spreads equally in all directions upon the human 
surface, as it does in the case of the "fairy rings," by sending out mycelial threads. 



448 TINEA CIKCINATA. 

Hence the irritation or inflammation will extend equally in all directions ; or, in 
other words, the eruption will be circular, and this indeed is one of the chief charac- 
teristics of tinea circinata. Then again the fungus, as it grows, is most active 
where its mycelial threads are actively forming and disturbing the tissues. It 
there does most mischief. The skin gets accustomed to its presence in the oldest 
parts of the patch, where the fungus assumes the cellular form, which does not 
irritate the tissues so much as the sprouting mycelium : hence redness, swelling, 
and vesiculation will be most marked at the circumference and less in the central 
part of the disease, conditions that constitute other very suggestive features of 
tinea again. The character of the fungus present will influence the aspect of the 
disease. If the conidial form prevail, the disease will assume less of the irritant or 
inflammatory aspect, and will at least not spread so rapidly as when the mycelial 
form is present. Now, it will be observed, when I come to speak of tinea circinata 
transmitted from animals, ex., the horse and calf, to man, that the characters of the 
transmitted disease are, as it were, exaggerated, this being explained by the fact 
that the fungus is of a very luxuriant kind in these animals at times, and, trans- 
ferred to the skin of man, irritates greatly. The mycelial form is found specially 
well marked in all cases in which heat and moisture are present, and hence in cases 
of tinea (eczema marginatum of the Germans) about the fork, and in ringworm of 
the surface that occurs in India and hot climates generally — ex. , Burmese ring- 
worm. Here the mycelium runs riot, as it were, at times, amongst the tissues : 
and red rings, rapidly enlarging over a wide area, are constantly seen in the 
disease. 

Now I make these remarks with the object of leading the reader to comprehend 
the matter of tinea circinata from anything but the narrow point of view generally 
taken by authorities and writers on the subject. Its cause is certain, but the 
effects of the growth of the fungus vary greatly, as I have explained above ; that 
is to say, tinea circinata is not uniform in aspect, but varies in that respect 
greatly. 



It was usual a few years since to call the disease 
circinata, which term signified that the eruption is herpetic in cha- 
racter. The fact of vesicles occurring depends solely upon the 
accident of the fungus producing such a degree of irritation as will 
be followed by a certain amount of effusion. But the fungus may 
produce less or more than this amount of irritation. I would 
define tinea circinata then as circular patches of inflammation in- 
duced by the growth equally in all directions of the trichophyton 
tonsurans upon the surface of the body, and varying in severity 
according to the degree of luxuriance of 'the fungus , and the degree 
of susceptibility of the skin of the attacked to inflame. 

I propose to describe first of all the ordinary or typical aspect, 
and secondly, uncommon phases of tinea circinata, such as general 
parasitic tinea, parasitic eczema, Burmese ringworm, eczema mar- 
ginatum, Malabar itch, Chinese itch, &c. • 

It will be seen that I include a number of diseases hitherto 
regarded as distinct from tinea circinata under that head. Of 
the correctness of this step I have no shadow of doubt, and it 
really saves a vast addition to the vocabulary of the dermatologist. 

The ordinary form of tinea circinata. — In its most common form 
tinea circinata consists generally of little circular patches of what 
appears to be ill-developed herpes, which becomes the seat of f ur- 
furaceous desquamation and the scales of which are invaded by a 
fungus. The whole is somewhat elevated. The edge is often dis- 
tinctly vesicular, and the patch increases in area by centrifugal 



TINEA CIRCINATA. 449 

growth. Itching is a common and marked symptom. The disease 
is mostly seen on the face, neck, breast, and upper limbs. It has 
been seen to travel upwards to the head, and become tinea tonsurans. 
The centre of the patch may be healthy, a ring of disease alone 
existing, and this ring may be vesicular or papular. It is sometimes 
epidemic in public institutions, in frequent co-existence with tinea 
tonsurans of the scalp —one disease giving birth to the other*. 
The fungus which invades the hairs as well as the epithelial scales 
(see figs. 68, 77), is the trichophyton tonsurans. In some cases all 
that exists is a little slight red distinctly scurfy patch, looking less 
than an herpes, and like a fading eczema. The patch originally 
appears of the size of a split pea ; then gradually enlarges, retains 
the circular form, and becomes faintly scaly. All that results is 
this red, circular, itchy, slightly scurfy spot. The disease is mis- 
taken as the rule for " pityriasis," or " dry eczema." It is a pri- 
mary form of eruption ; it may be associated with well-marked tinea, 
two or more persons in the same family being affected at the 
same time, whilst parasitic elements are detected in the scales 
with the exercise of due care. 

The nails may be attacked in tinea circinata, but I will speak of 
this under the head of onychomycosis, or onychia parasitica. 

Uncommon or Exceptional Forms of Tinea Circinata. — The cases 
to which I will first refer are those which consist of one or several 
large, more or less circular or oval patches, often seated about 
the back of the hand or the front of the wrist, which have the 
aspect of an eczema, but without the infiltration and the free 
crusting, but with a well-defined edge. They commence as ordinary 
tinea circinata, and gradually enlarge till they reach the size of a 
five-shilling piece, or the palm of the hand, and assume the aspect 
of eczema, and they are particularly itchy. They rapidly get 
well under the influence of parasiticides locally applied. I have 
called attention to these cases in several places and on several 
occasions. It may be difficult to detect the fungus in these cases ; 
and this leads me to observe that it by no means follows that the 
fungus is plentiful. In the eczematously disposed a very little 
fungus may excite a great deal of eruption, and the observer may 
search in vain for it in the seat of the secondary eczema, whilst it 
exists, plentifully even, in limited spots. But when found it will 
be distinct, well formed, if in small bits, as represented in fig. 73 — ■ 
which illustrates likewise another fact, that the 
fungus in these cases is very intimately connected Fig. 73. 

with the structures in which it is found — an indi- 
cation that its presence is not accidental. My 
friend, Mr. Tweedy, has examined a number of 
these cases of tinea, which have assumed the aspect 
of eczema, in the out-patients' department of Uni- 
versity College Hospital, and amply demonstrated 
the presence of fungus elements in the diseased structures. 
29 




450 TINEA CIECINATA. 

I have noticed that this exaggerated form of tinea circinata, 
consisting of circular patches, the size of from that of a shilling 
to that of a crownpiece, may even occur pretty generally over the 
body. It looks like an itchy eczema, of circular form ; indeed, 
these more severe forms, with well-defined margins, which tend 
to crnst over like an eczema, might be termed parasitic eczema ; 
and, in fact, the fungus acts as an ordinary irritant, and excites 
eczema. 

Another set of cases in which the features of tinea circinata 
have an exaggerated aspect, and in which the diseased surface 
appears to be studded over even with pustules in connexion with 
much swelling of the patches, are those cases which are occasioned 
by the transmission of the disease from the horse and the calf to 
man. But I will speak of these cases in detail presently, under a 
separate head, in dealing with the question of the transmission of 
tinea from animals to men. 

In the above phases, where the herpetic or vesicular character 
tends to predominate, the mycelial phase of fungus is found, but 
not in such luxuriant form as in the cases of tinea circinata 
— connected with the presence, especially, of more than the usual 
amount of heat and moisture in the skin attacked — about to be 
described under the terms eczema marginatum, Burmese ring- 
worm, &c. The reader will recollect that I use these designations 
merely as synonyms, holding strongly to the view that the term 
tinea circinata ought to include all those forms of disease to which 
they are applied. 

Eczema marginatum is tinea circinata occurring about the fork 
of the legs, and modified in aspect in consequence of the presence 
of heat and moisture in exceptional amount, and the luxuriant 
character of the mycelium of the fungus. It has been elaborately 
described of late by German writers, 45 " Dr. McCall Anderson, and 
others. In the year 1864, Kobner described the fungus, and 
inoculating his own arm with it, produced, as he asserted, tinea 
circinata. Iiebra thereupon questioned Kobner's diagnosis, re- 
garding the parasite as an accidental occurrence in the so-called 
eczema marginatum, but Pick's observations proved Kobner to be 
right. The disease, of which I have seen a great deal, begins as a 
red, scurfy, itchy spot, generally near the junction of the thigh and 
the scrotum ; and as it increases in extent, it festoons down over 
the thigh, the edge being well defined and often papular, the centre 
fading and assuming a brownish hue, and giving off scales on 
scratching. The disease may spread to the pubic region, the axillse, 

* Das Ekzetna Marginatum, cine Studie iiber die Natur und das Wesen dieser 
Krankheit, von Dr. P. J. Pick ; Arch, fur Derm, und Syph , i. i. p. 61. Also Hebra, 
Ueber den Befund von Pilzen, bei Ekzema Marginatum, von Prof. Hebra, Arch, 
fur Derm, und Syph., i. ii. p. 163. Also Zur Verstandigung liber das so Genannte 
Ekzema Marginatum, von Dr. P. J. Pick; Arch, fur Derm, und Syph., i. iii. 
p. 443. 



1UNKA CIRC IX ATA. 



451 



"\^S 



and the hairy part of the chest. In the fork of the thigh there are 
more heat and moisture present than in other parts of the body, 
and intertrigo is excited sometimes by the fungus : this furnishes 
conditions all the more favourable for the development of the 
fungus. If a portion of the scales be scraped off and examined 
under the microscope the fungus is readily detected. It consists 
of freely-branching mycelium, and oftentimes collections of spores, 
and thus closely re- 
sembles the fungus of yig. 74 
tinea versicolor. The 
fungus represented in 
fig. 74 was found in 
the scales of a well- 
marked case of so-called 
eczema marginatum oc- 
curring in the usual sit- 
uation. 

Eczema marginatum 
presents the same fea- 
tures as Burmese ring- 
worm, to be referred to 
directly. It is not of 
course so extensive or 
marked a form of erup- 
tion as Burmese ring- 
worm, as the rule, but I 
remember one case of 
the disease, sent to me 
by Dr. Evans, of Glou- 
cester, in a gentleman who had not been out of England, in whom 
large and well-marked patches of disease occurred over the 
pubic, perineal, gluteal, axillary, and pectoral regions, as ex- 
tensively as in any case of Burmese ringworm that I have seen. 
This gentleman perspired immensely, and insisted upon clothing 
himself in flannel, so that heat and moisture were present in force 
to give the fungus the best chance of luxuriating. But as Burmese 
ringworm is a matter of some clinical interest, I append the 
description of it, which I gave in another place recently." 




Fungus so-called eczema marginatum, a. Epi- 
thelial scales, b. Mycelial threads, c. Germinating 
coniclia. x 300. 



Burmese Bingicorm. — In various parts of the East many local designations are 
given to ringworm of the surface of the body (tinea circinata. as I have called it). 
There, in fact, would appear to exist in different places peculiar diseases, apparently 
different, but in reality one and the same in nature. Chinese, Burmese, and 
Tokelau ringworm are examples in question. It is pretty certain that these affec- 
tions are nothmg more or less than ordinary ringworm of the body, such as we 
have in Europe, determined in their occurrence to certain parts of the body by 
peculiar circumstances, and assuming characters somewhat different from those 



* Scheme for Obtaining s Better Knowledge of the Endemic Skin Diseases of 
India. By Dr. T. Fox and Dr. Farquhar. India Office, 1872. 



452 TINEA CIRCINATA. 

observed in the disease as it exists in colder climates, in consequence of the greater 
luxuriance of the parasite, consequent upon the presence in the one case of a greater 
amount of heat and moisture, which are favourable to the development and speed 
the growth of fungi. 

Burmese ringworm, of which I have had many cases under my care, occurs 
about the fork of the thigh, chiefly where heat and moisture are more influential 
than elsewhere, and in England I have seen the disease, in those who have returned 
from India, in two chief forms, or rather in two different degrees of extensiveness. 
In the one the disease consists in red itchy rings affecting the pubic region, the fork 
of the thigh, extending over the buttocks, and more or less about the axillse, the 
front part of the chest, and the parts covered by hair about the navel. The rings 
vary in size from that of a shilling to that of the palm of the hand nearly ; the 
colour is bright, the rings are itchy, and their surface is to some extent raised, and 
they leave behind furf uraceous surfaces. The aspect may be altered by scratching, 
so that the integuments become excoriated and infiltrated. All this means that 
the fungus is made up of actively-growing mycelial threads that sprout freely and 
forcibly amid the epithelial layers. Sometimes the disease seems to disappear, 
and only slight scaly, itchy, scurfy patches remain behind. Again it increases and 
reappears in all jts intensity. I have seen it limited to the face, and festooning 
down from the cheek to the neck. At the time of writing I have under care a gen- 
tleman with the face solely affected. He has just returned from Central America, 
and saw Devergie and Bazin in Paris, one of whom stated that the disease was due 
to shaving (Bazin), and the other to the action of the sun (Devergie). I detected 
under the microscope luxuriant fungus elements. 

In the other form or degree, the disease is less erythematous, does not take on 
the ring form, and appears to be limited to the fork of the thigh and the parts 
about it. There is a red, scaly, itchy surface, which festoons a greater or less 
distance down over the thigh in front, and attacks the perineum and the buttocks 
to some extent. The disease begins as a small itchy scurfy spot — that is to say, 
the fungus does not luxuriate so freely and so produce red rings — and as this spot 
spreads the centre pales or rather gets brownish ; the red edge extending. The 
edge is sometimes distinctly papular, and very well defined. The papules are 
mostly abortive vesicles, but even vesicles may be visible. If we pass the hand 
over the patches they feel thickened, dry, and harsh. If the disease is much 
scratched and irritated it may appear eczematous, or small boils may appear, or 
there may be a certain amount of lymph infiltration as the result of the irritation, 
and in such a form as to give the patch an uneven, somewhat knotty aspect, and a 
very rough feel. The disease may, after a while, break up into islets— one part 
getting better, another becoming worse, or remaining in statu qvo. The disease as 
a whole often, if left undisturbed, gets "better and worse." It is always itchy, 
especially with the warmth of the bed, and the skin is, in chronic cases, much dis- 
coloured. The fact that the disease occurs where heat and moisture are present 
accounts for the amount of change induced, and also the variation from ordinary 
tinea circinata, from which it differs mainly in being accompanied by more infiltra- 
tion. In fact, this description is that of the " eczema marginatum " of the Germans. 

Now it is easy to see that the occurrence of bright red rings in eczema margina- 
tum and Burmese ringworm is only a stage of the disease, occurring when and 
where the fungus happens to find itself in such a condition as to be able to sprout 
beneath the epithelial tissues far and wide, and that very rapidly. Sometimes the 
same red rings are observed in the onset of tinea versicolor, and I just now called 
attention to their occurrence in a case of eczema marginatum. But in most cases 
there is a more gradual growth of fungus, and the production of scurfy patches. 

Figure 75 is a representation of the mycelial threads of the fungus — the 
trichophyton — as seen in the scrapings from a case of Burmese ringworm recently 
under my treatment. The sketch is a rough one, but it will serve my purpose 
very well here. 

Malabar Itch, as far as I can make out, is the same disease as 
Burmese ringworm. 

Tokelau JZingworm. — Dr. Turner 45 ' speaks of a form of disease 

* Report of Samoan Medical Mission, dated Samoa, October, 1869. 



TINEA CIRCINATA. 



453 



called Tokelau ringworm, or Le Pita y after the name in the one 
case of a man — Peter — who is said to have brought the disease to 
Samoa, and in the other, the district from whence it came (Tokelau). 
It is said to be like ichthyosis, but is classed by Dr. Turner with 
herpes desquamans, and is probably a tinea circinata. 

The reader will now understand that tinea circinata, when it oc- 
curs in the fork of the thigh or is developed under the influence of 
heat and moisture, as in hot climates, is accompanied by a luxuriant 
growth of mycelium, which, F IG 75. 

spreading rapidly amongst 
the tissues, gives rise to cer- 
tain special appearances ; but 
these constitute no ground for 
instituting new diseases to 
be designated by the terms 
eczema marginatum, Bur- 
mese ringworm, and the like. 
The term tinea circinata in- 
cludes all these forms of 
ringworm. It is necessary 
only to remember that tinea 
varies somewhat with the 
locality of the body attacked, 
and variations in concomi- 
tant conditions, particularly 
as regards the presence of Trichophyton tonsurans, from a case of Bur- 
heat and moisture. mese ™%™™- 

Tinea Circinata Transmitted from Animals to Man. — I have, in 
speaking of favus and tinea tonsurans, noticed the apparent pro- 
duction of tinea circinata in man, from favus in animals ; and the 
development of tinea tonsurans from tinea circinata. I have now 
to speak of the production of tinea circinata in man from contact 
with animals affected by these diseases. It is well known that ring- 
worm of the surface may be transmitted from the calf and cow to 
man. I very recently communicated a series of most interesting 
facts to the Clinical Society* upon the transmission of tinea cir- 
cinata from the horse to man. The facts are of great clinical 
interest and there are two points I may briefly notice : the first is 
the transmission from the horse to man, which is not common in my 
experience — whilst recorded cases are not frequently to be met with ; 
and the second is, that the transmitted disease possesses features of 
an exaggerated tinea. The tinea circinata was transmitted to seven 
men from a certain pony, whose body was, when I saw it, covered all 
over with discoloured spots of a fairly circular outline, varying in 
size from that of a shilling to large irregular patches the size of 
the palm of the hand and more, the hairs of which had become 




* Clinical Society's Transactions, vol. iv. 



454: 



TINEA CIRCINATA. 



altered in texture and direction. They were curled and bent out 
of their proper, and into wholly different, directions. They were 
loosened, and readily came away from the follicle; some broke 
off ; they were also very opaque, and the surface of the skin was 
covered over by a mealy powder, thickly set about the hairs. In 
fact, all the characters of tinea tonsurans — ringworm of the hairy 
scalp of man — were present, as shown by microscopical examination. 
The accompanying illustration (fig. 76) shows the fungus in its 
mycelial and sporular form invading a small portion cut out of 
the shaft of one of the hairs of the horse, a, a, a are germinating 
spores ; they had an average diameter of -0012 inch. 

Now taking all the cases of the seven men who were infected 
by tinea circinata from the tinea tonsurans of the pony, together, they 
had these peculiarities in common : the patches varied in size from 
that of a shilling to the area of the top of an ordinary wine-glass, 
and they were seated about the arms and back of the hands chiefly. 

Fig. 76. 




The inflammatory aspect of the patches was more severe, the infil- 
tration more decided, the extent of the eruption greater than usual, 
and the herpetic character, when the earlier stages were observed, 
not at all abortive, but much more distinct than usual. More- 
over, the fungus, luxuriating amid the textures of the skin, set up 
so much irritation as to induce pustulation in place of the ordinary 
herpetic vesiculation in certain of the patches. In fact, the fea- 
tures of tinea circinata were not only peculiarly well marked, but 
exaggerated, and this was explained by the plentiful implantation 
of the fungus germs in unusual abundance and luxuriance, and the 
setting up by its vigorous growth of an unusual amount of irritation. 
So that, in fact, the disease looked like a well-defined eczema, in 
circular patches, and might have readily been mistaken for the same. 
Fig. 77 represents a portion of the epithelium from a patch on the 
arm of the man who looked after, and always groomed the pony, 



TINEA CrRCINATA. 



455 



Fig. 77. 




and it will be observed that it shows a most luxuriant growth 
of fungus in the mycelial and the conidial forms. There were 
miniature threads and also mature threads in abundance, breaking 
up into reproductive bodies, or conidia. 

" The transmission of so-called epizootic herpes, as ringworm of animals is called, 
from the calf and the ox to man, giving rise to tinea circinata of the non-hairy 
parts in adults, has been commonly noticed, especially in Ireland, notably in Cavan 
and Monaghan, the disease attacking the parts about the eyes, ears, the neck, the 
withers and limbs of calves, and I suppose 
that children may be, and no doubt are, 
affected with tinea tonsurans from contact 
with adults so attacked by tinea circinata, 
though there is no specific evidence on this 
point ; and a good paper on the subject 
has appeared from the pen of Dr. Tuckwell, * 
who details cases of tinea of the surface, of 
the head, and of parasitic sycosis, com- 
municated by tinea from the cow, in which 
the characters of those of an exaggerated 
tinea, as in my cases above described, were 
present. But I am not able to put my 
hand upon any save a few recorded instances 
in which man has become infected from the 
horse — an occurrence unknown at the Vete- 
rinary College. Mr. J. R. Dobsonf mentions 
the occurrence, and Bazin has observed the 
same in five men affected from a certain 
horse. A very instructive history of an epi- 
demic of tinea tonsurans, or as it was called 
epizootic herpes, occurring a few years 

since amongst some 300 mules and horses in the Valley of Borne, in Savoy, 
is given by Professor Papa, who was instructed to investigate the circum- 
stances connected with the epidemic. A number of instances are recorded 
in which the disease was communicated direct from the horse to man, and 
from man to man, man to wife, and wife to infant. The disease attacked 
the horses and mules about the head, the neck, withers, shoulders, and 
loins. It was itchy, and at first thought to be due to acari, but its real nature 
soon became apparent. In the cases observed by Professor Papa the communicated 
disease in the non-hairy parts of the men was an exaggeration, so to speak, of 
ordinary so-called herpes circinatus, or properly tiuea circinata, as in the cases 
which have just come under my observation, though this peculiarity was not 
pointed out by the Professor. The patches of disease were, I notice, said to be 
studded over here and there with small pustular points, indicative, as before 
observed, of a more than usual amount of irritant, and produced by a plentiful 
sowing of fungus elements upon the skin, and I take it that the reason why the 
disease was so certainly conveyed to man from the white pony, whose case I first 
noticed, is that the fungus elements were so very abundant and so very luxuriant — 
a point to be remembered in relation to the statement that as a rule ringworm in 
horses cannot be shown to communicate itself to men. 

" The production of parasitic sycosis in one of the men in the 
cases I have put on record, is very interesting, and furnishes one 
more strong fact in proof of what has been held of late by many — 
the identity, making allowance for difference of seat — of tinea ton- 
surans, tinea circinata, and tinea sycosis." 

* St. Bartholomew's Hospital Reports, vol. vii. 
f In his work on The Ox; his Diseases, and their Treatment, published 
in 1864. 



456 TINEA CIKCINATA. 

Mr. Fleming,* in commenting upon the above cases, mentions 
several instances quoted by authorities, in which tinea tonsurans 
was transmitted from horse to man. 

Diagnosis. — In arriving at a diagnosis of tinea circinata the stu- 
dent or practitioner must always bear in mind one or two points ; 
firstly, that as the rule the disease begins as a small itchy red spot 
and assumes rapidly the circular form, which it preserves ; that 
the edge of the patch is well defined, and that the intensity of the 
inflammatory occurrences vary according as the fungus grows 
rapidly or tardily, and the conidial or mycelial form predominates. 

Tinea circinata may be confounded with eczema, psoriasis, or 
pityriasis, but it has in reality no marked scaliness, as these have. 
Where the vesicular or quasi-herpetic character is not developed, so 
as to set the diagnosis at rest, it is always necessary to use the 
microscope. 

A more constant use of the microscope, indeed, in the diagnosis 
of cutaneous diseases, would land the practitioner clear of many 
errors, especially in reference to the discrimination of the exact 
nature and cause of eruptions that are mainly characterized, so far 
as naked-eye appearances are concerned, by " f urf uraceous " desqua- 
mation. It affords information as to whether, for instance, scales 
or apparent crusts are composed merely of epithelial, fatty, blaste- 
matous, or fungoid elements, or an intermingling of these morbid 
products in various proportions. The appearances presented in 
certain cases of psoriasis, in which epithelial elements alone are 
found : chronic eczema ; or tinea circinata in which inflammatory 
products are present in contrast with what is detected in cases of 
psoriasis ; or seborrhoea, in which perhaps only fatty matter is seen, 
or at least greatly preponderates : are often such as to lead to the 
individual recognition of these diseases. When the fungus ele- 
ments are detected — and they will be readily discovered oftentimes 
only in thin layers of material and closely incorporated with the 
epithelial elements — then the diagnosis of parasitic disease is certain. 

Treatment. — The cure of tinea circinata is usually a very easy 
matter indeed, especially if it come under the notice of the prac- 
titioner at an early date. The fungus is usually to be found attached 
to and amongst the scales of the epidermis, and is readily reached 
by parasiticides. But in some cases the fungus elements find 
their way to the hair follicles, and then there is more difficulty in 
getting rid of the disease. Ordinarily the patches may be gently 
painted over with acetic acid once or more, and they will disappear. 
To make the destruction of the parasite certain, the patient may 
be directed to rub in a weak white precipitate ointment or nitrate 
of mercury ointment ( 3 jss to § j) night and morning for a day or 
two. Solution of nitrate of silver in spirits of nitric ether : strong 
borax solution : ink even ; hyposulphite of soda lotion, 3 iv to § vj 

* Veterinarian for May, 1872. 



TINEA SYCOSIS. 457 

of water ; sulphurous acid lotion, one part to four of water ; or bi- 
chloride of mercury ointment (gr. ij to I j of adeps), are all good and 
efficacious. When the eruption occurs in schools it is of much im- 
portance to put a stop to the disease quickly and speedily, and 
under these circumstances the patches whenever detected may be 
touched with blistering fluid. 

In some instances the disease crops up both pertinaciously and 
freely here and there over different parts of the surface, and no 
sooner does one patch fade or go but others appear. I have always 
noticed the existence in such cases of a condition of system certainly 
not that of good health. The attacked are perhaps pale, or debili- 
tated, or there are faults as regards hygiene or diet. Such a condi- 
tion is to be met by remedies specially adapted to the lymphatic 
temperament ; and the dilute acids and bitters, or even arsenic, iron, 
quinine, and cod-liver oil, as the case may be, may be given. At the 
same time, beyond the use of the parasiticides to the affected places, 
sponging with hyposulphite lotion should be used to the parts of 
the skin around the diseased area. In eczema marginatum, a so- 
lution of bichloride of mercury (two grains of the latter to an 
ounce of fluid) is recommended by Dr. Anderson, and acts well. 
But I am in the habit of using a strong solution of hyposulphite of 
soda ( 3 vj ad | vj of fluid), directing patients to use soap and water 
freely before applying this lotion, in order to get rid of the greasiness 
of the skin, which repels the watery solution.. I direct that linen 
rags soaked in the lotion should be kept applied night and morn- 
ing for at least an hour at a time, covered over with oil silk. In 
some severe cases I touch the places with acetic acid first of all. 

In those cases in which the disease is more or less general, and 
tends to assume the eczematous aspect, I believe sulphurous acid 
lotion to be the best remedy. But if there is any discharge, it is 
preferable to employ an ammonio-chloride of mercury ointment 
(gr. v to I j of adeps). 

TINEA SYCOSIS. 

Under the term Sycosis have been mixed up two totally 
distinct things. Sycosis, as I understand it, means inflammation 
of the hair follicles of the beard. This may be non -parasitic or 
parasitic as regards its cause. The parasitic variety is infinitely 
rare in England and Germany, but common in France. The non- 
parasitic is common. The term tinea, when prefixed to that of 
sycosis — viz., tinea sycosis — indicates the parasitic variety of 
sycosis. I shall describe that now, and non-parasitic sycosis in 
the section which treats of diseases of the hair follicles. 

Tinea sycosis (mentagra, or sycosis menti, as it is called), as I 
have said, is a disease of adult life : and what is meant by this 
term is an inflammation of the hair follicles of the beard and 
whiskers, produced by the presence and growth of a parasite. 
Many (Wilson, Hebra, Simon, Wedl, and Hutchinson) deny its 



458 



TINEA SYCOSIS. 



parasitic nature. However, Dr. McCall Anderson and I are 
quite agreed upon the point. We together saw the fungus in 
abundance in the diseased subject, under the microscope, at 
Charing Cross Hospital some two or three years since, where I 
had the pleasure of meeting Dr. Anderson. I held the parasitic 
nature in certain papers originally published in the Lancet in 1857, 
and I have seen no reason to alter my views. I entirely subscribe 
to the views propounded by Dr. Anderson.* The truth is, that 
there is an impetiginous affection of the follicles of the beard that 
is likely to be, and is, mistaken for the parasitic disease ; but the 
former has an acute onset, it quickly spreads, involves the deep 
part of the corium and oftentimes the cellular tissue, and lacks 
the damaged hairs characteristic of true parasitic sycosis. In 
typical cases of true sycosis, which however are rare, the disease 
commences quietly and runs a chronic course. As a rule, the 
first thing noticed is a red itchy patch, which is really tinea cir- 
cinata, and this may escape notice, as it is concealed by the hair. 
After a while, as the fungus gets into and down the follicles, the 
latter inflame and enlarge ; subsequently induration takes place 
around the follicles, and shaving is painful ; there is also a slight 
burning sensation present. There may be one spot only of disease 
existing for a long time. But in other cases, after a while, 
successive crops of pustules appear, often grouped together, and 
to a limited degree occurs. Remissions are noticed in 
and summer. It is clear that the hair follicles are the seat 
of the disease, and the hairs themselves are altered, becoming dull, 

brittle, and loosened in 
Fig. 78. Fig. 79. the follicle, so that they 

are removed with ease. 
A fungus is to be found 
around and in the hair, 
but possibly not in all 
the inflamed follicles, 
because the original in- 
flammation set up by 
the parasite in one may 
be propagated to another 
through continuity of 
tissue. It must also be 
remembered that pas is 
a parasiticide to a cer- 
tain extent. Tinea cir- 
cinata may sometimes 
co-exist in other parts of 
the body. The fungus of 
sycosis (see figs. 78 and 79) is called Microsporon mentagrojphytes. 



crusting 



■ M 




Fungus of sycosis 
(shaft). 



Fungus of sycosis (towards 
root). 



Edinburgh Medical Journal for June, 1868. 



TINEA SYCOSIS. 459 

The spores are '003 to "004 mm. round, and more or less nucleated; 
in fact, they are much the same as the trichophyton. The mycelial 
threads are said to be branched at an angle of 40° to 80°, and to 
be annulated. The fungus is said to have its peculiar seat outside 
and around the hair. This is not absolutely true. 

I have now very frequently noticed, in certain cases, the hairs 
of the beard to be bent at one or more parts of their shaft, and at 
these bends what appear to be little white knots are seen. These 
knots, however, may be seated at any part of the shaft. When 
the hair is brushed it breaks off. This condition is seen in the 
beard and whiskers in adolescents and middle-aged men. On 
placing a " knot " under the microscope, it is seen at once that 
the fibres of the hair are separated, the fibres forming a little 
brush-like rim all round the shaft. On careful scrutiny, in some 
cases, fungus elements are seen upon and between the frayed-out 
fibres, and in minute form in the shaft itself. The hair can often 
be split up into two or three bands, after the addition of an alkali. 
Fig. 80 will readily explain 

this condition. I have also FlG - 80 - 

seen the free end of the hair 
present a brush-like appear- 
ance. Now I do not mean 
to assert that this condition 
is necessarily parasitic, be- 
cause if the hairs are badly- 
nourished from any cause, the 
fibres will be ill formed, and 
the hair will often break off 
and split up into fibres ; but I 
am pretty certain that occasionally the cause of the disorganization 
is due to parasitic action — I hope I shall not be misunderstood 
in this matter — it is due to a fungus getting into the root and de- 
veloping in the shaft after being carried some distance along it. 

Diagnosis of Parasitic Sycosis. — It can only be confounded with 
non-parasitic sycosis and acne ; the first is more extensive, often 
acute, has more crustiug, the hairs in it are not loosened, but 
cause pain in extraction. In parasitic sycosis, the origin from an 
- itchy, scaly spot, the induration of the separate spots, the absence 
of free crusting, the looseness of the hairs, and the presence of 
the fungus, as shown by the microscope, are distinctive. Acne of 
the beard resembles tinea sycosis. Other acne spots exist on the 
parts free from hairs or elsewhere, the hairs are not disorganized 
though they may be somewhat loosened, and there is an entire 
absence of parasite or its effects on the hair shaft. Syphilitic 
disease is known by its concomitants. 

Treatment consists of epilation and the use of a parasiticide. 
The treatment, in fact, is the same as that described as applicable 
to tinea tonsurans. (See formulae, Parasitical Remedies.) 




460 TINEA DEC AL VANS. 



TINEA DECALVANS. 



General Remarks. — At the present time there is a " dead set " 
made by almost every writer on diseases of the skin against the 
parasitic nature of tinea decalvans, and I believe I stand alone in 
my opinion of its parasitic nature. The chief ground upon which 
objectors claim its non-parasitic nature is that certain observers, 
especially the Germans, cannot detect the fungus. It might with 
as much reason be said that there is no parasitic sycosis on similar 
ground, or no prurigo, such as Hebra describes it, because it is 
not seen in England. But my complaint is that almost all writers 
have imagined that tinea decalvans and alopecia are one and the 
same thing. They may be quite different. Alopecia is the 
generic term for baldness; alopecia areata for localized baldness. 
Alopecia may result from tinea decalvans, it is true ; but tinea 
decalvans appears to be a specific and distinct affair from mere 
baldness, which is only an effect of the tinea. To take, as some 
have done recently, the first case of alopecia, and to draw conclu- 
sions from a chance observation or two of that diseased, often 
secondary condition, as regards tinea decalvans, is wholly unfair. 
However, I will not pursue this line of criticism, but proceed to 
state what my experience is. I find that to enter fully into the 
controversy of the parasitic nature of tinea decalvans would occupy 
too much space, and I must therefore reserve the polemical part of 
the matte]- for a more convenient occasion. 

Description. — This disease is characterized by the presence of 
circular, pale, bald patches, varying in size from one-third of an 
inch to one or two inches or more in diameter, which have been 
preceded by a certain amount of irritation. Patients say that 
they discovered a small bald spot, which has got steadily larger 
and larger. There may be several spots. There may be slight 
scurfiness. The patches are well defined. The disease attacks 

young people, and especially 
FlG - 81 - gh*ls, as far as I have seen. 

The hairs around the bald patch 
are more or less dry, come out 
readily, and are seen to be bulb- 
less, and tapering at their roots 
towards a point. But other 
broken-off short hairs stud the 
surface. Under the microscope, 

Minute fungus in tinea decalvans. in so ™ e ^Stances, at intervals 

on the shait, are collections 
of minute spores, arid also in the little masses of epithelium 
that stick to the hair. The hair may present bulgings here 
and there, which are due to the presence of abnormal granular 
matter, partly pigmentary, partly the minute stromal form of the 




TINEA DECALVANS. 461 

fungus, which is also scattered throughout the hair, and remains 
mostly undetected (see fig. 81). I have shown this repeatedly 
by artificial germination, by which I have obtained the distinct 
sporular form in the course of a few days from what appeared to 
be mere granular debris (see fig. 65). The fungus is the miero- 
sporon Audouini. The spores are from 2W0 o to 5 oVo- of an inch, 
the filaments few, wavy, and devoid of granules. The ordinary 
appearance of the fungus is seen 
in fig. 82. The fungus is some- Fig.- 82. 

times found in the epithelium at 
the extending edge of the disease. 
I believe, however, that it often 
lodges behind in the empty fol- 
licles, attacking the epithelial 
structures therein, and interfering 
with the proper re-formation of 
the hair. 

Now I am quite ready to admit 
that this parasitic disease is not 
common — far from it, and that 
the majority of cases of circum- 
scribed baldness observed in the 
head are not parasitic at all. 
But I cannot but state that I have found fungus elements without 
doubt, and so have others at University College. And I must 
here at once emphatically deny that what I have described as a 
fungus is nothing more or less, as suggested by my friend 
Dr. Duhring, of Philadelphia, than broken-up sebum. It is not' 
upon the presence of the cellular form of fungus alone that I rely 
in diagnosing the parasitic nature of the disease, but also of distinct 
mycelium. ' Whether the fungus I have found is sufficient to pro- 
duce the amount of hair-mischief present may well be open to 
question ; and there are other considerations. I have seen a patch 
of tinea decalvans, on a head affected at the same time with tinea 
tonsurans. I have seen more than one and more than two members 
of the same family affected at the same time with tinea decalvans: 
and the disease has occurred as an epidemic. A remarkable case 
in point was afforded at Hanwell* a few years since, where the 
disease spread from one to between thirty and forty children in 
the same part of the building ; the ordinary fungus was detected 
in these cases, which are alone explained by the contagious nature 
of the disease. This outbreak was investigated by the late 
Dr. Hillier, my predecessor at University College. It has been 
suggested that he erred as regards the diagnosis. I can under- 
stand an error as regards a solitary case, but I cannot believe that 
Dr. Hillier could perpetuate the error through some forty instances. 

* See British Medical Journal, February 29, 1868. 



462 TINEA VEKSIC0L0R. 

The whole matter is one not for decision at present but for 
investigation, and especially in reference to the asserted existence 
of transitions between the disease and tinea tonsurans — and their 
co-existence in the same subject. 

I have said that localized baldness may be produced by other 
than parasitic causes, and the confusion of the parasitic and non- 
parasitic forms has led to great difference of opinion, which still 
exists. In any atrophy of the skin, the tapering hairs (atrophied 
roots) may be found. I believe also that bald patches may be the 
result of a failure locally in the nerve-activity or an atrophy pur 
et simple J and, indeed, the hair of the scalp, eyebrows, pubes, and 
whiskers may disappear ; but in these instances there is always 
thinning of the entire derma ; the hair follicles are invisible, par- 
ticipating, themselves, in the general atrophy; the sensibility is 
diminished, so that the application of strong vesicating fluids 
scarcely irritates the scalp, if it does so at all. There is a general 
thinning of the hair during the progress of the baldness, and often 
antecedent neuralgia or some definite impairments of nutritive power 
traceable to an efficient cause, and no parasite to be found. On 
the other hand, in the parasitic alopecia, as I have observed it, 
the hair follicles are visible, there is not airy diminution of sensi- 
bility more than is due to the inactivity of the follicles, and there 
is often antecedent erythema, with concomitant scaliness over the 
bald patch, whilst the loss of hair is in strong contrast to a vigo- 
rous growth — often of dark black hair around — on a head with a 
good crop of hair. But, as I have said, I am open to conviction, 
and hope to be able to specially investigate the matter. 

Diagnosis. — This has been sufficiently indicated already in the 
above remarks. 

Treatment. — A host of panaceas have been suggested, but I 
cannot mention these here. My plan is to blister all patches that 
are rapidly on the increase with blistering fluid, to pull out a few of 
the hairs around the patch, if they are at all loose, then to rub in 
for ten days or a fortnight bichloride of mercury ointment (gr. ij 
to 1 j), and finally, to stimulate with mix vomica, cantharides oint- 
ment or lotion ; and by perseverance I scarcely ever fail in speedily 
restoring the hair to the part. I give iron, cod-liver oil, bitters, 
or other drug, as the special nature of each case may require. 

TINEA VERSICOLOR. 

Tinea Versicolor, formerly called Chloasma or Pityriasis versi- 
color, often commences as little erythematous points, attended by 
itching, which is increased by warmth of all kinds. This stage, 
however, is rarely observed. 

Typical Cases. — The patient presents him or herself with 
patches of a fawn colour, which are slightly elevated, dry, 
rough to the touch, somewhat scaly at the edge, and from which 
branny scales can be rubbed off. These patches are itchy, 



TINEA VERSICOLOR. 



463 



especially when the body is warmed. They are chiefly met 
with on the parts covered by flannel, and, it is affirmed, in 
phthisical patients, but certainly those who perspire freely. The 
disease may be made up of one or two small patches, or the front 
and back of the chest may be dotted over with small isolated 
patches, or small patches varying in size from a threepenny 
piece, intermingled with larger ones the size of the palm of the 
hand ; or the patches may run together, and the whole of a large 
area may be uniformly affected — ex., the front of the chest, or the 
back, or the sides of the chest, or the whole front of the arm. Chlo- 
asma is especially common on the front part of the chest and 
belly. If the scales be examined, their under surface will be 
noticed to be studded with little collections of spores arranged in 
heaps, and mycelial threads freely interlacing. The minute hairs 

Fig. 83. 




Microsporon f urfurans. 

of the part are more or less infiltrated and the fibres split up. 
The disease has been noticed by myself to be produced by the im- 
plantation of the oidium, and by Mr. Hutchinson from the fungus 
of tinea tonsurans. The plant is the Microsjporon furfur (Eich- 
stadt) — see fig. 83, from a sketch of my own. The spores average 
in size between '0008 and *002 mm. ; they are round, do not contain 
granules, are said to be " bilinear," and to be collected into little 
heaps, which are sub -epidermal. The mycelial threads are much 
branched and wavy. The resemblance between this fungus and 
that found in tinea circinata of the fork is at times complete. 

Unusual Forms. — In some cases tinea versicolor, instead of 
presenting the appearance of distinct fawn-coloured patches, has a 
reddened and punctated appearance. This is seen about the centre 



464 TINEA VERSICOLOR. 

of the chest in front, and between the shoulders behind. The ex- 
planation of this condition is to be found in the fact of the disease 
being more or less limited to the hair follicles. The surface is 
closely dotted over with reddish points, each of which is surrounded 
by a certain amount of brown staining — that is to say, the disease 
extends a little way or is limited as it were to a small distance, 
around each hair follicle, the central red point indicating the 
opening of the follicle. If careful attention be directed to the 
point, small patches with much the ordinary characters of tinea 
versicolor may be detected here and there. These smaller spots 
may coalesce more or less, and form extensive patches in some 
cases. I have seen the disease in the form, in the early stage, of 
erythematous rings, with a slightly discoloured centre, and it is by 
no means unusual in hot weather to notice the edge of the patches 
become distinctly erythematous. The ordinary characters of tinea 
versicolor, however, are observed in the central part. I have also 
seen the disease in the form of small dirty light-brown spots, the 
size of from split peas to threepenny-pieces, clotting the entire sur- 
face of the body," and the scales from which showed very luxuriant 
fungus under the microscope ; and this leads me to make reference 
to the term, pityriasis nigra. 

Willan, it may be remembered, described a variety of pityriasis 
which occurred in young children who had been brought from 
India to England, and which was remarkable in the fact that there 
was a black discoloration in connexion with furfuraceous exfolia- 
tion. Cazenave mentions that many cases of this disease were seen 
in Paris in 1828-9. English writers do not seem to have met with 
such cases, but an instance, in an adult, of what had all the appear- 
ance of & pityriasis nigra came under my notice a year or two since. 
The man was forty-one years of age, and had had the disease for 
twenty-one years. He got it in the Mauritius. The whole of the 
back and lateral parts of the chest were covered by an almost sooty- 
black desquamating discoloration which in the centre of the chest, 
in front, was much lighter. The eruption was at once seen to be 
the ordinary tinea versicolor, complicated by marked pigmentary 
deposit, and it was proved to be such as suspected by the micro- 
scope. The subject was of the bilious temperament, and of 
Spanish origin. No one seems to have hitherto suspected for the 
patient the parasitic nature of the disease. The patient got well. 

I have on one occasion seen tinea versicolor complicated by 
urticaria, the latter being well marked at the extending edge of a 
large patch of the tinea. 

Lastly, I have observed tinea versicolor become very much in- 
flamed and take on the aspect of an eczema. A very remarkable case 
of the kind came, amongst my out-patients, to University College 
Hospital, in the early part of the present year (1872). The man, 

* Lancet, February 15, 1868. 



TINEA VEESICOLOK. 465 

who worked in a hot room, was the subject at first of tinea versi- 
color in well-marked patches over the chest and the arms. At his 
second visit most of the patches over the arms presented the ap- 
pearance of an eczema of moderate severity, and the one state 
developed out of the other. The cure of the eczema was soon 
found in the destruction of the parasite of the tinea. And clinically 
and therapeutically it is of importance to know that an eczema may 
be excited bj parasitic fungi and occur as a secondary consequence 
of their growth on the skin. If the eczema were not treated with 
parasiticides, it would last almost any time. I have already, in 
speaking of tinea circinata, mentioned that this disease may assume 
an eczematous phase. 

Now these unusual forms — the punctuated, the erythematous, the 
markedly discoloured, and the eczematous — are not common, but 
no one ought to be ignorant of their possible occurrence. In 99 
cases out of 100 tinea versicolor has the readily recognizable char- 
acters I have described as belonging to the typical variety. 

Diagnosis. — I am constantly in the habit of seeing patients with 
pityriasis versicolor who have been treated vigorously for secondary 
syphilis. Such a mistake ought not- to occur. It is generally 
when the P. versicolor is extensive that error is made, but syphilis 
never produces an extensive fawn-coloured staining like P. ver- 
sicolor, nor staining as the sole existing evidence of disease, 
and syphilitic stains are never elevated, and desquamating. But 
I will give as follows the diagnostic points in the two cases: — 
Syphilitic stains are brownish ; are attended by a history of 
syphilitic infection ; are preceded by roseolous rash and slight 
pyrexia, with congestion of the fauces, &c. ; are seated on all parts 
of the neck, breast, face, forehead, and arms ; are without itching 
as a rule ; have often a circular form, varying in size from that of 
a fourpenny to that of a two-shilling piece ; are without desqua- 
mation ; are not elevated ; occur together with other forms of 
secondary disease often present ; and there are no parasitic ele- 
ments found in connexion with them. In P. versicolor the colour 
is fawn-coloured ; there is no syphilitic history as the rule ; no 
antecedent erythema as the rule, no roseola, no pyrexial symp- 
toms, no throat congestion, &c. It occurs on parts covered by 
flannel, generally ; is accompanied by troublesome itching, in- 
creased by warmth. The patches generally are of irregular shape, 
often of large size after the disease has existed for a while. Des- 
quamation is usual ; branny scales can always be scraped away 
from the patch, which is slightly elevated, whilst the eruption is 
uniform. No concomitants of syphilis are present, and parasitic 
elements are easily and always detected in the scales. 

Chloasma of course may occur in men who have had syphilis, 
and with some frequency perhaps, but then the elevated fawn- 
coloured desquamatory aspect of the tinea ought to suffice for 
direct diagnostication. Melanoderma may resemble tinea versi- 
30 



4c66 ONYCHOMYCOSIS. 

color, but there is no desquamation and no parasite, as there must 
be if the extensive staining were parasitic. 

Treatment. — I have one mode, and it is always successful. I, 
first of all, have the part washed with yellow soap, then sponge 
with a little weak vinegar-and-water, and apply freely a lotion 
composed of four or six drachms of hyposulphite of soda and six 
ounces of water. A hyposulphite bath once or twice, if the cure 
be obstinate, will aid somewhat, but I never require much else 
than this for any case. The secret of the cure consists in getting 
off by the use of the watery lotion the greasy matter of the skin 
with soap, and in continuing the use of the parasiticide for some 
time after all appearance of the disease has vanished. 

Tinea tarsi comes under the notice of the ophthalmic surgeon ; 
but it may be as well to say that the inflammatory state of the 
Meibomian glands frequently seems to depend upon the presence 
of the trichophyton. 

ONYCHOMYCOSIS, OR ONYCHIA PARASITICA. 

These terms are used to designate disease of the nails due to the 
attack upon them of vegetable parasites. 

The nails appear to be parasitieally affected as a complication 
in several of the varieties of tinea already described — in tinea 
favosa, tinea tonsurans, tinea circinata, and tinea decalvans; but 
parasitic disease of the nails (onychomycosis) may exist as the sole 
disease present — that is, as an independent condition. I have 
seen all these conditions except onychomycosis in connexion with 
tinea decalvans. Speaking generally, the effect of the attack of the 
fungus upon the nail, is to thicken it, to render it brittle, to break 
it up into layers, and to make it opaque, or it may be yellowish. 
The seat of the fungus growth is shown in some cases in the early 
stage by yellowish specks imbedded in the nail, and the fungus 
oftentimes attacks in the first place the side or the part near the 
root of the nail, giving rise to a certain amount, it may be, of in- 
flammation and discomfort. 

In regard to favus attacking the nails, I may quote the descrip- 
tion of T)r. Fagge * on a case of the kind. He exhibited a child 
eleven years of age, who had been suffering from favus of the head 
and limbs for a long time, and the nail of whose left little finger had 
become diseased within three weeks of the date of his exhibiting 
the case. The tubes and conidia of the fungus were seen to pene- 
trate the substance of the nail, gradually invading it till they 
reached its root. The laminre of the nail then became loose. The 
progress of the disease thus differed entirely from that usually de- 
scribed to be the common one, according to which a favus-cup 
forms beneath the nail and gradually perforates it. The part of 

* Report of Clinical Society for March 13, 1868. 



ONYCHOMYCOSIS. 



467 



the nail attacked was of a sulphur colour, and when the strata had 
been scraped off, the bed remained covered with an irregular 
striated mass of nail substance of a dark or yellowish hue. The 
fungus is the achorion. 

The disease (onychomycosis) is by no means a rare complica- 
tion in tinea tonsurans. One or two illustrative cases will be 
found recorded by Dr. Purser* and Dr. Fagge.f Dr. Purser gives 
the following description : — Nail dirty brown, streaked with lines of 
a darker colour, greatly thickened, and at its free extremity sepa- 
rated from its bed by a mass of soft-nail substance which could 
easily be picked out. Tne entire nail was somewhat roof-shaj)ed, 
a prominent ridge running along its centre ; its surface was uneven 
and traversed by rough lines; longitudinal striae well marked; 
the nail had a tendency to split up ; and the microscopic appear- 
ances of a bit of the nail were as follows : it contained (1) spores 
like those of trichophyton ; (2) filaments tortuous and branching, 
jointed and containing nuclei ; (3) larger, less branched, brownish 
filaments, containing spores, walls of many indistinct, looking like 
moniliform chains ; (4) granular matter. In a second case the 
appearance of puccinia was simulated. Dr. Purser correctly 
describes the fungus as a trichophyton. 

Dr. Purser's description is a very good one : the nail is rough 
and uneven, and in places has a worm-eaten appearance, or por- 
tions of its laminae break off, and on examining scrapings under 
the microscope, the fungus elements are detected. I have usually 
found the conidia large, and mycelium made up of beaded rows 
of largish sized cells. 

This condition of nail I have seen produced in those who have 
attended to children's heads affected with ringworm, in one or more 
nails, and as an independent 
state of disease or preceded 
by tinea circinata of the fin- 
gers or back of the hand, 
which has spread to the nail, 
and in that way infected it. 
The accompanying figure 
represents portions of the 
fungus elements found in the 
scrapings of the nail of a lady 
who had made the necessary 
applications to the heads of 
some children attacked by 

tinea tonsurans, and the practitioner will usually find the fungus 
in this form. 

Onychomycosis may likewise occur without seeming to have 
originated as the complication of tinea circinata, or from tinea 



Fig. 84. 




* Dub. Quarterly Journal, Nov. , 1865. 



f Guy's Hospital Reports. 



468" MADURA FOOT. 

tonsurans, or favus ; that is to say, it may develop without there 
being any evidence of its having been caused by ringworm of the 
body or the head. Fagge* has described onychomycosis in con- 
nexion with tinea decalvans ; but as before stated I have not seen 
this. 

Diagnosis. — This is made by paying attention to the co-existence 
of parasitic disease, and by the microscopical examination. It 
must not be forgotten that the nails are rendered opaque, thick, 
and brittle in connexion with psoriasis, pityriasis rubra, lichen 
ruber, and the like ; but in parasitic cases the evidence of the con- 
nexion between the nail and the general disease and the origination 
of the former from the latter is usually clear. 

Treatment. — This is, in the majority of cases, very satisfactory, 
but in order that a successful result may be attained speedily, it 
is necessary that the parasiticide should be made to reach the 
deeper parts of the nail, and that the nail structure should be kept 
soaked in the parasiticide lotion. I usually scrape off some of the 
loose laminae of the nails, then apply every second or third day some 
strong acetic acid to the seat of the change, the whole nail area if 
necessary, taking care not to make the matrix too tender : and then 
keep the nail or nails soaked in a solution of hyposulphite of soda 
( | ss or 3 vj to 1 vj of water). Perseverance with the lotion will 
certainly cure the disease. 

MADURA FOOT, OR FUNGUS FOOT OF INDIA. 

Synonyms. — The other terms applied to the disease are Mycetoma, 
signifying the causation of the malady by a fungus ; Ulcus grave ; 
tubercular disease of the foot ; Morbus tuberculosis pedis ; and 
Podelkoma. 

Description and General Remarks. — A good deal has been written 
and said about this disease, from time to time, by Eyre, of Madras, 
Ballingall, Bagunjee Rustomjee, Day, Yandyke Carter, Minas, 
W. J. Moore, of Rajpootana, and Dr. Bidie, and sufficient to make 
us well acquainted with its characters. Dr. Carter was the first to 
discover a fungus in the disease, and to suggest that as the cause, 
but it is difficult to gather from his writings in how many in- 
stances he has detected the fungus; and other Indian officers, 
save Dr. Bidie, do not appear to have met with it. I have had 
the opportunity, through the great courtesy and kindness of 
Dr. John Shortt, of Madras, of carefully examining several ex- 
cellent specimens of the disease which he has sent home to me, 
and have in only one case detected the fungus, but it may have 
perished on the voyage in the others. 

The disease when fully developed consists of marked swelling 
of the affected part — generally the foot, though it may be the 
hand, or even, it is said, the shoulder — which is studded over with 

* Clin. Soc. Trans, vol. i. p. 77. 




MADURA FOOT. 469 

little soft buttony elevations about the size of a pea, having a 
central aperture leading into a sinus. The buttony enlargements 
are studded over themselves with little black grains or masses like 
fish-roe (see fig. 87), which also 
collect about the openings of the Fig. 85. 

sinuses. From the sinuses are dis- 
charged black-and-white particles, 
with thin sero-purulent fluid. The 
accompanying representation (fig. 
85), after Mr. Minas,* gives some 
idea of the appearance presented 
by the foot attacked by the disease. 

If a section of a diseased foot is made, there is found, as stated 
by Dr. Vandyke Carter : — " General confusion of parts, owing to 
absorption of the bones and fibrous thickening of the soft parts ; 
often the presence of granules, separate or aggregated in mulberry- 
like masses of a yellow or brown colour, lodged in spherical 
cavities excavated in the bone or in the soft parts, or in tunnels 
or channels leading from the cavities to the apertures on the 
surface, also lined by membrane. These granules are present in 
the discharge ; sometimes there is a deposit of fleshy (may be 
reddish or dark-coloured) substance, containing numerous minute 
particles (white or red), and occupying the same localities as the 
above-mentioned granular deposit. Lastly, in the same localities 
we find black granules, spheroidal tuberculated masses of the same 
colour, radiated in structure, which have been mistaken for me- 
lanosis or blood clots." These black masses are the fungus. Ap- 
pended to the accompanying fig. 86 is Dr. Carter's description of 
the red fungus. 

I can quite confirm Dr. Carter's description as applicable to 
certain cases, but I have very carefully examined other specimens 
in which there was one feature entirely wanting — viz., the presence 
of the black granules and masses in the spherical cavities, all else 
being the same, even to an abundance of roe-like particles. (See 
figs. 87, 88.) Such a specimen I presented to the Pathological 
Society of London on the 19th October, 1870, and it was referred 
for a detailed examination and report to Dr. Moxon, Mr. Hogg, 
and myself. AVe very carefully examined the foot, and made the 
following report : — 

' ' The soft parts of the foot are swollen ; but the muscles are degraded and 
wasted, so that it is difficult to recognise them. The swelling arises partly from 
increase of the subcutaneous fat, and partly from the size and numbers of the 
canals. The several tissues are traversed in all directions by these canals, which 
branch and intercommunicate. The bones as well as the soft parts are pierced by 
them, but the tissue of the bone, even close to the walls of the channels, is qiiite 
healthy-looking. The walls of the channels are composed of a soft greyish filmy 
substance, continuous with and not separable from the tissues around. Micro- 

* Indian Med. Gazette, May 1, 1863. 



470 



MADURA FOOT. 



scopic examination does not reveal any structure in this substance, except a few 
fibrils and a defaced nucleus here and there. The contents of the channels are 
not connected with their walls. They correspond to the descriptions of fish-roe- 
like substance which is described as filling these canals in the second form of 

fungus foot, except that they do not show any pink colour There was no 

trace of structure that could be set down as that of fungus. The cells and fibres 
that Dr. Carter has described in the black matter of his first form of fungus foot 

Fig. 86. 




Chionyphe Carteri. 
(The original drawing of Carter reduced to one-quarter.) 

1. Red Fungus which grew on the surface of the fluid covering the 
portions of afoot affected with the " Black Fungus," magnified to show 
its development from the germinating sporidia, a, «, a, to the formation 
and bursting of the spore /. 

a, a, a, a. Germinating sporidia. #, b, b. Commencement of spore-cells 
containing nucleus, c. Nucleus and contents of spore-cell further ad- 
vanced, d. Apparent quadruplication of contents of spore-cell with 
further subduplication of their interior, e. Spore and sporidia formed. 
/. Spore bursting, g. Sporidia more magnified to show shape and 
nucleus, h. Spore embraced by a condensation of small filaments, very 
common if not constant. 

2. Felt-like form of the layer of Red Fungus as it grows in the bottle. 
a. Filamentous layer, b. Layer of spores, c. Filamentous layer below. 

3. Filament to show that it is composed of cells with a nucleus in the 
upper end of each. 

Filaments -g-Arcr ha diameter ; sporidium -g^Vo - long. 

Spore, largest piece, 5^0 m diameter, 
we could not see any sign of. His opinion that the rounded bodies composing the 
fish-roe -like substance are made up of defaced fungus structure, coated with fringes 
of fat crystals, may be correct ; but we must remark that if so, the defacement of 
the fungus character is curiously complete. On the other hand, these rounded 
masses (see fig. 87, after Carter, natural size, colour, and appearance ; fig. 88; one 
of the masses magnified, -S-inch object glass), with their covering of sub-filamentous 
material, have a very uniform appearance, such as suggests to us a less accidental 
nature than that attributed to them by Dr. Carter. The substance of the little 
rounded masses is softly granular, and has in some instances a texture of fine 



MADURA FOOT, 



471 



fibrils in it, like those of coagulated fibrin. The surface of each mass is rounded 
and its curve is perfect, but we cannot see any nuclei or cells upon it. The sub- 
filamentous material presents at first sight the appearance of a ciliated epithelium, 
as its component matter gathers itself into masses about the size of the cells, and 
these masses will separate and float about, but in them, when separate, there is no 
nucleus to be seen, but only faint fibril- 



lation ; in some instances these filaments 
are separated from each other. They 
are not acted upon by acetic acid, 
caustic soda, or potash of moderate 
strength. The filaments bend in a wavy 
manner, and appear entirely devoid of 
rigidity such as characterizes crystals. 
(See fig. 88.) 

' ' We are of opinion that the nature 
of these remarkable structures requires 
further investigation, directed rather to 
their stages of development or of further 
transformation than to their minute 
structure. We think that their very 
constant and peculiar form, and espe- 
cially the sub-filamentous covering of them 
definite than perished fungus." 



Fig. 87. 



9 



•<•; 




& 



marks them as something more 



In a second specimen of the disease which I still more recently 
exhibited to the Pathological Society of London, the black masses 
referred to by Dr. Carter as lying in spherical cavities, were present 
in abundance in loculi in the foot, and these black masses were 



Fig. 89. 



Fig. 90. 









carefully examined by Dr. Bristowe and myself, and found to be 
made up of fungus elements, having the characters of oidium. 
Fig. 89 is Dr. Bristowe's representation of the fungus as he saw 



472 MADURA FOOT. 

it after boiling in potash. Fig. 90 gives the appearance of a piece 
of the black masses magnified ten times. Fig. 89 is, in fact, one 
of the terminal points of fig. 90, magnified 420 times. There still 
remains, however, the fact that in one specimen where the foot was 
greatly disorganized there was no fungus at all to be found. So 
that, after all, it may be that there are two aspects of the disease — 
one in which fungus is a complication, and the other in which it 
is absent. 

The most striking difference between the anatomical appearances 
in the two phases of fungus foot would appear to be the absence 
in one, of the loculi (above and beyond the channels) filled with a 
black truffle-like mass of fungus. The similarity as regards the 
perforation of the whole tissues by channels giving out the fish- 
roe-like masses is complete. The question suggested here is this. 
Is the presence of the fungus an accidental phenomenon ; and 
does it find its way through the sinuses running from the surface : 
and there luxuriating, develop for itself by its growth loculi in 
the tissues? To determine this, it is necessary to learn the 
appearance of fungus foot in its earliest condition, and this has 
yet to be made out. There are one or two other points to be still 
further considered in regard to the appearances presented by the 
fully-developed disease. 

Absence of Black Matter. — It does not follow that because we in 
England have found no black masses in certain cases, that they may 
not have existed to some extent in specimens prior to their being 
sent to this country ; for, in the instance which Dr. Moxon and I 
myself examined, and in which no trace could be found, black 
matter was discharged from the sores in the foot before it was 
amputated, so we were informed, and when the amputation was 
performed, it was noticed that " the medullary part of the bones 
just above the ankle was infiltrated with a black fluid, the disease 
having extended up into the tibia." The nature of this black 
matter is uncertain. Is it fungus or blood ? Some of it is certainly 
altered blood, and blood is sometimes discharged from the openings 
in the foot (?) And this leads to another very important point. 

State of the Bones. — In some cases where the disease has appeared 
to be confined to the bones of the foot, and where no sign of 
disease has existed in the integuments of the leg, it has been noticed 
that when the leg has been amputated just below the knee, "the 
bones were unusually soft, and yielded readily to the saw," and it 
is in such cases that grumous black fluid is found infiltrating the 
medullary substance of the bone shaft upwards towards the soft 
part. In other cases this accompaniment of the disease has not 
been observed. We especially refer to Mr. Wright's observations 
in the Guntoor district. The condition of the bones themselves 
is sometimes simply that observed in an ordinary cases of necrosis. 
There is a fine specimen in University College Museum of the 
entire bones of the foot illustrating this point. In other cases the 



MADURA FOOT. 473 

bones in part are affected about the neighbourhood of the joints ; 
and in others, the bones are shelled out completely in parts, 
forming the walls of cavities enclosing black masses. Sinuses 
always lead down to the diseased bones. 

Joints and Cartilages., — In those cases which we have seen, it has 
been observed in tracing the disease upwards from very diseased 
joints to joints commencing to be affected, that the articular 
surfaces about the ligaments were chiefly affected. Whether this 
is always so in the early stage remains to be proved. 

Mode of Origin and Cause. — How does all the disease above 
described arise % This is a most important question indeed. We 
are told that Mr. Bagunjee Itustomjee (Dr. Carter's paper) found 
" in the early stage little or no swelling of the foot ; the integu- 
ments are natural in colour, or slightly congested and hot, having 
in the surface elevations, which when burst or opened, allow a 
thin yellowish puriform disc barge to exude, containing granules 
like poppy-seeds. The skin in the plantar surface is irregularly 
thickened and converted into knots at intervals, and gives, on 
handling, the feeling of lumps." 

I have the history of four of Mr. Wright's cases. In one, 
"about ten years before, the patient noticed a small boil or 
pimple on the sole of the right foot near the toes : a few months 
after, others appeared, but no further change occurred for eight 
years, that is, two years ago," when the whole foot swelled and 
became painful, and discharged a blackish matter. In the second 
case, the man u noticed two years before a small pimple on the 
sole of the foot near the smaller toes, which came into an open 
sore. Other sores then appeared and the foot swelled generally 
with discharge of black matter." In case three, the man " noticed 
a small blister on the inner side of the left foot, when the ankle 
began to swell and sores broke out in different parts of the foot, 
discharging a glairy fluid and blood, but no black matter, it 
seems." In the fourth case, about eighteen months before ad- 
mission, he " noticed a small sore between the big and second toe 
of the right foot ; the toes then began to swell, fistulse formed." 
Mr. Minas noticed in the case of the hand the first appearance to 
be a bluish discoloured swelling. 

Xow it will be observed here that there is no absolute proof 
that the surface disease is not an evidence of deeper-seated disease 
— I do not affirm it is ; but what is wanted is a careful examina- 
tion of a whole foot when the early stages above described are 
present, to ascertain what is the condition of the deeper parts ; for 
it will be remembered, as stated just now, that very serious disease 
of bone may exist, to be discovered during amputation, for 
instance, when no evidence of its existence is afforded by the 
condition of the soft textures covering it. If the disease begins 
from without, and travels inwards, and is produced by an external 
cause, then in the earliest stages the deeper parts would be found 



474 VAGINAL AND ANAL MYCOSIS. 

healthy, and the superficial parts affected in the way above 
described, and it would be possible to be able to trace the progress 
of the disease in more advanced cases, from without inwards. 

The real questions awaiting determination are the existence or 
not of deep disease first of all without f angns ; or the origination 
of the disease in the superficial parts, and its travelling from 
without inwards or the reverse, in connexion or not with the 
presence of fungus elements ; and these are problems now before 
Indian medical officers.* 

The Treatment. — This consists in amputating the foot or other 
part affected if the disease be well marked, and in partial amputa- 
tion and the free use of caustics if it be in an early stage. 

MYRINGOMYCOSIS. 

Another disease to note under this chapter is one caused by the 
growth of a fungus within the meatus of the ear. It has been re- 
described by Wreclen lately, in the " Comptes Rendus," Aug. 26th, 
1867, and named myringomycosis or mycomyringitis — outlandish 
terms both of them. The fungus is the aspergillus nigrescens and 
flavescens, having all the characters of a glaucus save in colour, 
or an ascophora elegans. In four out of ten cases, Wreden found 
the disease on both sides. There was much derangement of the 
function of hearing and a good deal of irritation. The fungus 
tends to form an interlaced mass of fibres or rather a white 
shining tissue, studded here and there with black points (asper- 
gillus nigrescens), or brownish yellow (A. flavescens). The injec- 
tion of a weak solution of hypochlorite of lime or arsenite of potash 
is recommended by Wreden. The same authority suggests that 
the source of these moulds may be the walls of uncleansed and 
stuffy rooms. 

VAGINAL AND ANAL MYCOSIS. 

In pruritic irritation of the vagina, oidial forms of fungus may 
be present as the cause. This has been called vaginal -mycosis. 
A parasiticide at once stops and cures completely the pruritus, 
which otherwise might be troublesome. Anal irritation in children 
after thrush may arise from a similar cause. 

* For further discussion of this point, see Scheme for Obtaining- a Better Know- 
ledge of Endemic Skin Diseases of India, prepared by Dr. Tilbury Fox and Dr. 
Farquhar. Ladia Office, 1872. 






CHAPTEK XXI. 

DISOEDERS OF THE GLANDS. 

There are two sets of organs to deal with here — the sweat or 
sudoriparous, and the fat or sebaceous glands. I think both these 
parts of the skin are much more frequently disordered than is 
generally supposed. I shall speak first of — 

L DISEASES OF THE SWEAT GLANDS. 

The deviations from health may be functional or structural : the 
former include all those cases in which the sweat varies in amount 
and kind, but in which there is no change in the actual tissue of 
the glands or follicles themselves ; the latter those in which the 
sweat follicles are likewise congested, obliterated, inflamed, en- 
larged, or otherwise structurally altered. 

The disorders may be arranged thus : — ■ 

A. Disorder of Function, including hyperidrosis (excessive 
sweating), dysidrosis, or excessive secretion with retention and its 
effects, anidrosis (diminished perspiration), osmidrosis (change in 
odour), and chromidrosis (change in colour). 

B. Structural Disorder: miliaria and sxtdamina (congestive 
disorders), lichen tropicus (folliculitis), strophulus (inflammatory), 
hydro-adenitis (suppurative), and cysts, due to follicular obstruction. 
The above disorders may be more or less intermingled. 

I wish particularly to call attention to a phase of hyperidrosis 
which might be termed hyperidrosis with retention, but which I 
have designated dysidrosis — an eruption usually regarded as an 
eczema of the hands. It bears the same relation to the sweat 
glands as acne does to the sebaceous glands, and has not yet 
been described as it should be. First, then — 

A. FUNCTIONAL DISEASES OF THE SWEAT GLANDS. 
Hyperidrosis. — Hyperidrosis is the term applied to excessive 
sweating. This hyperidrosis is, however, not very often an inde- 
pendent form of disease. It occurs in connexion with general 
febrile disturbances, as in pneumonia, phthisis, rheumatism — 
appearing to be " critical *' in some cases. It may, however, 
occur as a purely local disease, and then the excessive secretion of 
sweat takes place from the face, the hands, the feet, or the armpits, 
and it is very annoying. A similar state of things is natural to 
some persons. The sweat may be very offensive (see osmidrosis). 
Hyperidrosis may give rise to eczema and intertrigo, as about the 



476 dysidkosis. 

feet frequently. In some cases hyperidrosis, that is, a freer 
secretion of sweat than usual, may be conjoined with or followed 
by more or less congestion of the follicles, and then the morbid 
states known as miliaria and lichen tropicus result (see further on). 
If the sweat fails to escape it ma} 7 collect under the cuticle, 
forming sweat vesicles. This is sudamina, 

DYSIDROSIS. 

This disease, which I now describe in detail for the first time, 
is characterized essentially by the retention in the follicles of the 
skin, of sweat rapidly and freely secreted. The follicles are much 
distended, and the retention of the sweat and the distension of the 
follicles are followed secondarily by congestion of the sweat fol- 
licles, by the formation of bullae, maceration of the epidermis, and 
it may be, more or less dermatitis. This disease bears the same 
relation, in fact, to the sweat follicles as does acne to the seba- 
ceous follicles. I shall not fail to explain the differences which it 
presents from sudamina and miliaria. The disease is of common 
occurrence, and it is regarded as an eczema. I don't know that I 
can bear stronger testimony to the correctness of my views as 
regards the separate and distinct character of the disease than by 
stating that those of the students of the hospital to which I am 
attached who have attended the skin clinique there for only a short 
time, are enabled to recognise the disease with readiness, and to 
give at once its distinctive features and its pathology. 

Clinical Features. — This eruption varies much in intensity. In 
its slightest form it is confined to the hand, occurring in the inter- 
digits over the palm, and along the sides of the fingers, and on the 
palmar surfaces — some or all of these parts. The eruption makes 
its appearance in those who habitually perspire freely, and gene- 
rally in the summer, but oftentimes in the winter ; and the patients 
attacked complain of feeling weak and depressed. The eruption 
is made up, in the first instance, of minute vesicles deeply im- 
bedded in the skin. The vesicles are at first isolated. They do 
not readily burst, and when they have existed for a few days the 
appearance of the affected part is just as though a number of small 
boiled sago-grains were imbedded in the skin. These sago-grain- 
looking points are caused by the distension of the sweat ducts by 
clear sweat, whose transparency contrasts with the aspect of the 
follicular wall and adjacent j3arts. These beaded or sago-grain-like 
imbedded vesicles are often well seen at the tips of the fingers on 
the palmar surface, but in severe cases, more or less all over 
the palm of the hand, and in fact, the fingers. There is always 
much itching and a good deal of burning present with the erup- 
tion. As the disease progresses the vesicles get more distended 
and become raised. They are not pointed but ovalish ; they 
eventually become faintly yellow in colour, and run together into 
the form of aggregated masses of small bullae. Actual bullae of 






dysidkosis. 477 

greater or less size may form. The hand is then very stiff and 
painful. I have seen the back of the hand and the palm, with 
bullae upon them an inch in height. If the vesicles be pricked, a 
fluid like clear serum oozes out (altered sweat), and it is at first 
alkaline and then acid. If the vesicles and bullae be left undis- 
turbed, the fluid is partly absorbed and, I imagine, partly evapo- 
rated away, the cuticle then peels off, leaving a non-discharging, 
reddened exposed derma. But the cuticle, especially about the roots 
of the fingers on the palmar aspect, may become socldened, and 
like wet chamois leather. In some of the slighter cases the disease 
does not run on to the develojnnent of bullae. In the severer and 
the slighter forms, one or both hands may be affected. When the 
eruption is disappearing altogether from the hand, the palm is left 
harsh and slightly scaly. It has been mistaken for syphilitic 
disease, but there is no deposit, and the palm is not thickened or 
tuberculated. 

ISTow there are certain other phenomena, varying under different 
circumstances, observed in this disease. 

First, as regards the Eruption. — The eruption about the hand or 
hands may be complicated by a rash, more or less general over the 
body. In some cases it may be limited to the back of the hand, 
and the fore-arms, or it may be in severe cases of the disease seen 
about the face, the neck, and on the trunk, the body, and the feet. 
This eruption is similar to that of lichen tropicus and miliaria; 
it is hyperaemia of the sweat follicles. It is very itchy. The same 
state of things as exists in the hands may be present in the feet, 
large bullae forming, but the sago-like grains will be found at the 
extending edge of the disease. At times the vesicular eruption 
when in its confluent form about the palm and fingers, presents,' 
after it has existed a little while, a peculiarly yellow look, like 
slightly yellow wax or honey. There may be one or more outbursts 
of the eruption, and the disease lasts ten days or so in some cases, 
but in others for two or three weeks. In some cases, when the 
outpoured sweat goes, a red, dry, slight scurf y, painful — sometimes 
awfully painful — surface is left behind, and becomes chronic. Pa- 
tients in whom this occurs are thin, pale, anxious looking, depressed, 
and so on. They require careful general treatment for the removal 
of the nervous debility that exists, when the hand or hands will get 
well. In these cases the sweat ducts are frequently seen dilated 
here and there over the affected surface, and never seem to recover 
their proper calibre. 

Secondly, as regards- General Symptoms. — I never knew any pa- 
tient who had this disease I am now describing, well. In all the se- 
verer cases patients have been the subject of great nervous debility, 
and in some cases have been under the care of physicians for various 
anomalous nervous diseases — odd muscular affections. Some have 
been prostrated by mental anxiety or worry. They always " perspire 
too freely," are speedily exhausted, and are often dyspeptic. 



478 DYSIDKOSIS. 

The origin of the disease can be clearly made out as a distension 
of the sweat duct, and not only its superficial but also its deep 
part, and then this is followed by the continued distension of the 
duct, the aggregation and coalescence of the vesicles, aud some- 
times the results of the maceration of the parts attacked. 

Its Alliances and Differences as regards other Diseases Like It. — 
This disease has, as before stated, been described as an eczema, but it 
lacks the catarrhal feature of eczema. It is not inflammatory ; it 
is unaccompanied by sero-purulent discharge, by crusts, or the like. 
The vesicles are not produced by the uplifting of the cuticle by 
sero-purulent fluid, but by the distension of the sweat follicles by 
retained sweat. Nothing is more striking about the disease than 
the absence of anything like sero-purulent fluid in the disease, and 
crusts formed by drying up of inflammatory products. Eczema 
may, however, and does rarely follow the disease, I admit, but not 
frequently. 

As regards sudamina, these occur in connexion with many febrile 
disturbances, and are not due to distended sweat follicles so 
much as to the uplifting of the horny layer of the cuticle by sweat. 
The opening of the duct lies at the base of the vesicle. (See p. 91). 

The red papules seen scattered over the surface at times, no 
doubt constitute miliaria, but this is only a complication — just 
what might be expected where the sweat function was disordered ; 
and no doubt sudamina are sometimes present also. 

From these remarks it may be gathered that the sweat gland as 
a whole is involved in the disease I have now described. 

Cavse. — This I do not pretend to define. I only know that this 
disease occurs under such circumstances that it may with proba- 
bility be supposed that the innervation of the gland is specially 
at fault. It seems to me that there is a sudden influx of sweat, and 
the flow is so rapid that it cannot escape, the whole gland is dis- 
tended, at least its duct, and the fluid presses in from below only 
to block up the upper portion of the duct by pressing together the 
twists of the duct in that part of the cutis where it runs in a spiral 
manner. If there is sudden pressure from below, the spiral twist of the 
duct must greatly favour the obliteration of the duct. In sudamina, 
I take it, the opening is plugged by exuvia, and the sweat finds its 
way laterally between the horny layers of the cuticle ; the secretion 
of sweat is not so free nor continuous, because not due directly to 
special nerve paresis. The explanation of the causes of the disease 
I have been describing, and its differences from sudamina, is, I take 
it, to be discovered in some such direction as I now suggest. 

Diagnosis. — It must be distinguished from hyperidrosis, eczema, 
syphilis, tinea circinata, and erythema papulatum. In hyperidrosis 
there is a large amount of sweat poured out upon the surface, it 
is not retained to distend the sweat follicles. I have already 
referred to the difference between this disease and eczema ; nothing 
could be more different than the origin and course of eczema and 






DTSIDROSIS. 479 

dysidrosis. When the disease is disappearing, that is to say, when the 
sweat collected into the follicles and in the bullae has dried away, 
and the cuticle is peeling off, sometimes a reddened dry, harsh, 
slightly scaly surface is left behind, and this looks like a tinea 
circinata, or a scaly syphiloderm ; but the history of the case in 
dysidrosis at once clears up all doubt, for the patient explains that 
the particular stage and aspect now referred to was anteceded by 
the formation of vesicles and bullae. In tinea circinata the fungus 
elements would be detected, the disease affects the back of the 
hands, and arises from small red, itchy, scurfy places primarily. 
In syphilitic disease, the derma being affected, the disease is deeper, 
therefore the surface is altogether more harsh and thicker ; w T hilst 
dysidrosis, so far as the inflammatory state of the skin is concerned, 
is very superficial. Then in syphilodermata there are significant 
concomitants, and their origin cannot be traced back to an eruption 
of a vesicular character of acute nature. They are also tubercular 
in form. 

Treatment. — This consists, in the severer form of the disease, in 
both general and local remedies. The patients who suffer from 
this disease, as I have stated before, are the subjects of anomalous 
nervous symptoms. They are thin, they fatigue easily, they as- 
similate badly, and they are often anaemic. Some require the 
removal of dyspepsia, some anaemia, some do best with the mineral 
acids and strychnine, so far as these are calculated to suit particular 
cases. But before attempting to improve the general health, it is 
desirable to begin in all cases with diuretics, and the kidneys 
should be made to act freely. This is not an empirical mode of 
procedure, because by it the skin is relieved of so much work. 1 
give acetate of potash with ammonia and some juniper as the 
rule, together with some simple aperient. The patient should 
avoid fatigue and hot drinks, and should be quiet in the house till 
the worst of the disease is over. If the patient be rheumatic or 
gouty, and the urine very acid, I find it a good plan to give 
alkalies with a freer hand, and I prefer large doses of Yals water 
with the meals. If when the disease shows itself the patient be 
specially weak, and particularly if there be anything like neuralgic 
symptoms, it is well to combine the use of quinine in full doses, 
if it can be taken — gr. ij to gr. v for a dose — with the diuretic 
medicines. In certain females, with loaded systems and ame- 
norrhoea, aloes may be given with advantage. When the disease 
subsides, anti-dyspeptics, followed by courses of arsenic and iron, 
with or without cod-liver oil, will generally improve the general 
health greatly. As regards local measures, there is much to be 
done to alleviate the pain and discomfort. The body generally 
may be covered with miliary eruption. The itching that accom- 
panies this may be greatly relieved by bran and soda baths, or a 
lead bath, made by adding a pint of lead lotion to a bath. The sur- 
face may be sponged with a calamine (Formula 117), or weak lead- 



480 OSMIDROSIS. 

lotion. (See also Formulae 88, 110, 135.) But the body may not 
be affected, for the hands alone are frequently attacked, but 
whether by themselves or in connexion with the body, they require 
careful management. The action of diuretics internally, and the 
exhibition of quinine, will serve to some, often to a marked extent, to 
check the rapid secretion of sweat ; but if the disease be seen in the 
earliest stage, something may also be done in the same direction 
by binding up the -fingers and hand in weak lead solution. Pre- 
sently, however, the tense and painful hand will not bear this 
treatment. In that case, relief may be had by puncturing the 
sago-grain-like vesicles and the bullae, when not a little fluid will 
escape. The hand should then be encased in oil, or the old uug. 
plumbi co. of the old London Pharmacopoeia (Kirkland's neutral 
cerate), and dressed twice a day. The disease must, as nurses say, 
" come to its height," and then subside, and it is at this very 
period that much good is to be done by keeping the parts encased 
in oil or emollient unguent, to prevent them getting harsh, and 
to enable the derma to recover its healthy state when the cuticle 
peels on and leaves it in a red and tender state. If a chronic red 
and scaly surface is left behind, it must be treated tenderly, and 
the medical man must trust to internal tonics to improve the 
general health, and so influence the local disease. Put a borax 
lotion, and by-and-by a weak tarry ointment, may be used to 
stimulate the surface somewhat into healthy action. Some cases 
of the severer form are a long time getting well. 

In the slighter cases, the internal use of quinine and emollient 
lotions and ointments soon remove the disease. 

The main thing to do is to make a correct diagnosis, lest the 
disease be treated as eczema, or syphilis, or scabies. 

Anidrosis. — This disease is characterised by a diminution of 
perspiration. A dry skin is part of many general diseases — ex., 
fevers, diabetes, and of certain skin affections — ex., xeroderma, in 
which there is a congenital defect of nutrition. More commonly, 
it arises from allowed inaction of the cutaneous covering ; and the 
use of friction, warm bathing, alkaline baths, and the like, gene- 
rally brings the skin into a proper state of action. There is of 
course in these cases more or less general debility, which should 
receive special attention in each instance. 

Osmidrosis. — This is that disease in which the odour of the 
perspiration becomes so offensive as to constitute " the thing to 
be remedied." 

Osmidrosis may co-exist with other functional derangements of 
the sweat apparatus. In general diseases the sweat exhibits very 
peculiar odours — in rheumatism it is " rank," in scurvy " putrid/' 
in chronic peritonitis " musky," in itch " mouldy," in syphilis 
" sweet," in jaundice " musky," in scrofula like " stale beer," in 
intermittent fevers like "fresh-baked brown bread," in fevers 
" ainmoniacal," and so on. When the feet are affected, the sweat 



CHR0MIDR0SIS. 48 1 

is sometimes most offensive, especially in the summer time. 
Ilebra describes this condition very fully. The hands and feet of 
the afflicted are cold without their knowing it ; the feet exhibit 
shining drops of sweat ; the epidermis is macerated, and presents 
a white wrinkled appearance; a certain amount of excoriation 
may result ; and with these conditions an offensive odour exists. 
Hebra believes that the smell is not inherent to the sweat, but 
(external) in the boots and socks. This is, no doubt, true to some 
extent, but it would seem also that where the greatest cleanliness 
is observed, some people's feet are most unfortunately not of the 
sweetest smell. There is often a blueness due to inactive circula- 
tion in the tissues. The treatment is a matter sometimes of great 
tediousness. Much may be done by rigid cleanliness. If the 
disease be due to saturation of long-worn socks and boots, with 
acid sweat which decomposes in them, then the removal of the 
cause of offence is easy. In ordinary cases the feet should be well 
washed or bathed in a solution of alum or Condy's fluid. The 
use of a light sock and shoe, lotions of creasote, or finally strap- 
ping each foot for twelve hours together, as suggested by Ilebra 
and Martin, with diachylon plaster, may be combined with tonics. 

Chromidrosis. — This term signifies coloured perspiration, a con- 
dition by no means common. The perspiration may be changed 
to a black, a blue, a red, or a green colour in certain cases. The 
black (melanidrosis) and the blue (cyanidrosis) varieties of per- 
spiration are probably the same in nature, the substance giving 
the colour being identical, but varying in hue in the two cases. 
The literature of this subject is not a little extensive, and cases 
have been recorded specially by Billard,* J^eligan,f Barensprung, 
Wilson, Le Roy de Mericourt,^: Gintrac, Lecat, Gallot, Teevan, 
Bousquet, Banks, Lyons, Macken, Duchenne,§ (the first two regard 
it as a simulation), Gilbert, Robin, Foote,| Kollman, Bleyfuss, 
and a very host of other writers. 

It generally occurs in hypochondriacs, or in women with uterine 
disorders of different kinds. It is seen as a symmetrical affec- 
tion attacking mostly the eyelids, and the lower one chiefly, but in 
other instances and more rarely the upper eyelid, the cheeks, the 
forehead, the sides of the nose, the breast, the stomach, and the 
hands. It consists of an oozing of black matter which can be 
wiped away, but only as a rule to quickly reappear. The dis- 
coloured secretion is excited by grief, by emotions, by fright, and 
the like, it is said. 

The disease may be simulated. In a case referred to by 

* Archiv. Generates de Med. See Cyanopathie Cutanee. 

f Dub. Quarterly Journal, 1855. 
\ Memo-ire sur la Chromidrose ou Chrornocrinie Cutanee. 

§ Gazette des Hopitaux, 12 Mai, 1859. 

|| Dub. Quarterly Journal, May, 1866. 

31 



4:82 H^EMATTDEOSIS. 

Duchenne, a woman avowed that she had painted her face during 
a period of twenty years to simulate the disease. 

But there appears to be no doubt that there is a real chromi- 
drosis. I cannot enter into detail here, but refer the reader to 
Le Roy de Mericourt's essay for much valuable information, and 
I content myself by saying that Dr. Foote,* in a good paper on the 
subject of chromidrosis, has given the particulars of thirty -eight 
cases. He found that the disease was most common in women 
about the age of twenty-two, being twice as frequent in the un- 
married as the married, and often preceded by uterine disturbance. 
The colouring matter is probably incliccui, which is, as it normally 
exists, colourless, and occurs pathologically in human urine. The 
indican is believed to be secreted by the sweat glands in a colour- 
less state, and to be acted upon by the air so as to be oxidized 
blue, or brown, or blackish, as the case may be. In one case 
which Scherer examined, the patient had been taking a large 
quantity of iron, and Scherer found the blue colour to be due to 
protosulphate of iron. 

H^ematideosis (Bloodt Sweating) occurs under similar circum- 
stances, and is supposed to be due to the escape into the sweat 
glands of blood from the capillaries, in its turn the result of 
great excitement ; and, as Neumann observes, the disease is really 
an extravasation of blood into the sweat glands. 

Greex-colottred Sweating. — The occasional occurrence of pro- 
fuse sweating, the sweat having a green tint, due to the presence 
of copper, has been described by writers. Dr. Claptonf has 
recently put on record a certain number of 

"Cases of copper-poisoning- occurring amongst the out-patients of St. Thomas's 
Hospital." In these cases the copper has been taken into the system with the 
food, or by workpeople in the course of their accustomed occupations. One was a 
sailor, who "had been compelled, during the whole time of a long voyage, to 
drink lemon-juice, which was kept in a copper tank." Another was a young 
woman, an artificial-flower maker, who " was in the habit of inhaling the dust of 
verdigris and Scheele's green," which she used in her business. A third case, a 
coppersmith in an engineer's factory, led to the discovery that all the persons 
working in a particular shop, fifteen in number, were similarly affected. The 
general symptoms induced by the copper, which were of a chronic character, 
were : — vertigo, gastrodynia, flatulence, dyspnoea, frequent vomiting 1 , wasting of 
the body, coppery taste, lassitude, and indisposition to exertion ; the tongue moist 
and flabby, and pulse hard and full. In all, there was a green stain of the edge 
of the gums extending halfway up the tooth. The perspiration of these people 
' ' had a bluish tinge. I examined the flannel waistcoats of several, and found them 
deeply stained, especially under the arms. One of the men stated that, even after 
a hot bath on Saturday night, his white shirt next day, if in hot weather, would 
be quickly discoloured. I noticed, too, that the wooden handles of all the hammers 
were stained green from the perspiration of the hands. " " Even with the greatest 
care, it is impossible to prevent the inhalation of copper particles or fumes. The 
dust of the shop, when viewed in a bright ray of light, can be distinctly seen to be 
charged with bright metallic particles. Water, too, kept in any vessel in the room 

* Dub. Quarterly Journal, 1868. 
f Med. Times and Gazette, vol. i., 1868, p. 658. 



MILIARIA AXD STJDAMIPrA. 



4S3 



for a short time, can be shown by tests to be charged with -copper. The fumes 
given off during the process of strongly heating the copper for the purpose of 
joining appear to be most injurious." 

In all cases of chromidrosis it is the first duty of the physician 
to see that he is not being cajoled. 

B. STRUCTURAL DISEASES OF THE SWEAT GLANDS. 



Fig. 91. 



Under this head I have included miliaria and sndamina (for in 
these the vascular plexuses of the follicles are specially involved) ; 
lichen tropicus and strophulus, and hydro-adenitis or suppurative 
inflammation of the follicles. 

Miliaria and Sudamina. — These two affections really have no 
right to be considered as separate diseases. Sndamina is the lesser 
degree of miliaria, the contents of the vesicles being acid ; miliaria 
is the more developed condition, in which inflammation has 
occurred and the contents are alkaline— in fact, inflamed sucla- 
inina. Sudamina have been 
described as little round 
vesicles, produced by disten- 
sion of the cutis by sweat, 
and therefore seated at the 
orifices of the sweat follicles. 
The accompanying figure of 
Dr. Haight's gives the exact 
structure of the vesicles in 
sndamina. The gland duct, 
in fact, has nothing to do 
with its formation, for the 
fluid is found between the 
horny layers of the cuticle, 
and the opening of the duct 
is seen at the bottom of the 
vesicle. It appears to me 
that the opening of the duct 
gets plugged by collected 
epithelium in cases where 
the perspiratory function is p^rT 

in abeyance for a time ?s a layer of^pid* 

111 levers I and when the Skin horny layer. B. Cavity of the vesicle. D. Canal 
begins again to perspire, the of the sweat duct. 8. Excretory duct of the 

sweat cannot escape, but sweat £ ]and - 

finds its way beneath the cuticle. The sweat gland itself is scarcely 
at fault. The vesicles of sudamina may be attended with more or 
less inflammation. Then the disease is termed miliaria. Some- 
times the vesicles are reddish (miliaria rubra), sometimes white 
(miliaria alba). These vesicles are developed about the neck, 
axillae, clavicles, and trunk, in diseases in which profuse sweating 




23- 



Stratum Malpighii covered by 
c. 



4S4: LICHEN TROPICUS. 

occurs ; their contents quickly dry : each crop is usually succeeded 
in from three to six days by furfuraceous desquamation. The 
disease is seen in phthisis during summer-time, in acute febrile 
diseases, the parturient state, rheumatism, fevers, and the sweating 
disease of Picardy. Since the adoption of a cooler regimen in 
sick-rooms, the disease has been altogether less frequent than 
formerly. So-called miliary fever (said to occur in two forms) is 
characterized by profuse sweating and the development of suda- 
mina. The treatment demanded is a cool regimen. 

Strophulus. — I have already described this form of disease (see 
p. 153), and I there stated that it was, as depicted by writers in gene- 
ral, a mixed affair; one item of which is simply a congested 
condition of the perspiratory glands ; in fact, a miliaria. 

Lichen Tropicus, or Prickly Heat. — This has nothing to do 
with lichen. It is a congestive or inflammatory disorder of the 
sweat follicles of the skin. It might be called hydro-adenitis tropica. 
It occurs as the result of the stimulant action of heat upon the 
surface. It is therefore common in hot climates, but not rare in 
hot weather in England, as I can fully testify. " Prickly heat " 
is generally described as an eruption of numerous papillae of vivid 
red colour, about the size of a pin's head, without redness of the 
skin generally, often interspersed with vesicles and accompanied 
by a peculiar tingling and pricking sensation, which may be almost 
intolerable, and is excited and intensified by heat, warm drinks, 
flannel, &c. The disease attacks chiefly the parts covered by the 
clothes, the arms, legs, breast, thighs, flanks, and the upper part 
of the forehead. As I have said, the anatomical seat of the 
disease is the perspiratory follicles. The great demand made upon 
the perspiratory glands deranges their circulation, so much so, 
that they are mostly unable to excrete sweat ; the result is con- 
gestion, and then the surface is not properly cooled by evapora- 
tion, the sweat products are retained, and consequently the 
nervous plexus of the skin is acutely disordered : hence the 
burning, pricking sensation. Here and there over the surface a 
certain amount of perspiration is produced, this collects beneath 
the cutis, and forms vesicles. It is not uncommon to find liche- 
nous papules intermingled with those of prickly heat, and even 
enlarged sebaceous follicles. These are accidental phenomena, 
the result of the disorder of the circulation through the skin. 

The Treatment consists in the adoption of a cool regime, in 
avoiding the influence of all accelerants of the circulation, such as 
the drinking of hot liquids, or the eating of condiment, or the taking 
of stimulants ; then in giving diuretics freely to relieve the con- 
gested skin, and in using locally bran baths, with slight astrin- 
gent and cooling or anodyne lotions to the skin. But I much 
prefer diuretics followed by quinine in good doses, alkaline baths, 
and locally calamine lotion (see Formula 117). 



HYDRO- ADENITIS. 485 

Hydro-Adenitis. — Verneuil* described this disease hydro-ade- 
nitis. It is an inflammatory state of the perspiratory follicles, ending 
in suppuration. The disease may occur in every region of the body 
where there are glands, except in the sole of the foot ; but it is 
most frequent in the axilla, at the margin of the anus, and near 
the nipple. It also is seen on the face. The disease commences 
by a crop of, or perhaps only one or two small inflammatory, tu- 
mours, always distinct, about the size of peas, of bright red hue, and 
(says M. Yerneuil) at first like boils ; but they are unlike boils 
in the fact that the little inflamed indurations begin not on the 
surface of the skin, in a sebaceous or hair follicle, but beneath the 
skin, which is reached and involved secondarily. The suppurating 
follicles offer no prominent " point " or " head," and there is no 
discharge till the swelling bursts, wheu the disease is brought to a 
sudden termination. The causes are said to be uncleanliness, 
friction, the contact of irritants, pus, parasites, profuse perspira- 
tion, and, according to Bazin, the arthritic dyscrasia, syphilis, and 
scrofula, but nothing is known about this. The disease is often 
mistaken for scrofuloderma. It is, however, very clear that there 
is a disease in which the actual coiled sweat gland becomes in- 
flamed and often suppurates, and Verneuil is correct in describing it 
as commencing in deeply placed quasi-blind boils. The treatment 
consists in the use of alkalies internally, hot fomentations, and 
soothing applications — lead lotion and the like — externally. I find 
collodion the best thing. 

I have had several cases of this disease under my care. The 
last was that of a young woman who had two or three red, subcu- 
taneous " lumps " under her eye of bright red colour, and the size 
of peas, with no central suppuration. In a couple of weeks the 
tumours " broke," and the face rapidly got well. 

Cystic Formations (Obstructed Sweat Glands.) — In some cases 
one sees developed in the skin a cyst, which takes its origin in a 
dilated follicle or sac of the perspiratory gland. The follicle of the 
sweat gland becomes obstructed, and instead of the gland inflaming 
and suppurating, the fluid collects and distends the follicle. The line 
of demarcation between hydro-adenitis and cyst formation in the early 
stage is not well-defined. I have seen " serous" cysts of this kind form 
on the face from the closure of the perspiratory ducts occasioned by 
the cicatrices of acne in a strumous subject, and most difficult the 
disease was to cure. I find the continuous application of collo- 
dion the best treatment ; the cysts, however, may be punctured, 
and the contents allowed to escape ; the incisions must, however, 
be deep enough. 

* Journal of Medicine and Surgery, Oct. 1866. 



486 SEBOEEHCEA. 

II. DISEASES OF THE SEBIPAEOUS OR SEBACEOUS GLANDS. 

As in the case of the sweat glands, I may divide the diseases of 
the fat glands into two groups. 

a. Functional — including seborrhea (increased secretion), astea- 
tocles (deficient secretion), and alio st eat odes, or alteration in the 
character of the secretion. Retention of secretion is usually ac- 
companied by alteration of structure, and I shall describe it under 
the latter head. 

b. Structural — including diseases of the lining membrane of 
the sebaceous glands — ex., pityriasis, xanthelasma : retention of 
secretion and its consequence — as seen in comedo, sebaceous cysts, 
molluscum contagiosum, and lastly, congestive diseases and in- 
flammatory diseases — acne, &c. 

A. FUNCTIONAL DISORDERS. 

Seborrhcea or augmented secretion of fatty matter, sebaceous flux 
— the stearrhcea of Wilson — is not so very uncommon in the various 
diseases of the surface, in which the skin is generally congested 
and the glands become sympathetically irritated or inflamed from 
their nearness to the seat of morbid action ; in elephantiasis, and 
oftentimes in the early stages of syphilitic eruptions of the scalp, 
it is a marked feature. Some persons have naturally a greasy skin. 

When Seborrhcea occurs as a separate disease, its most usual 
seat is some part of the face, especially the nose, and it mostly 
shows itself in the form of little yellowish thin crusts, which on 
examination are found to be made up of sebaceous and epithelial 
matter, the epithelial cells of the sebum being loaded with fat in- 
termingled with free granules and cholesterine ; the skin beneath 
the fatty plates is reddened, more or less thickened, and the seba- 
ceous glands are lrypertrophied. The disease presents on the scalp 
the aspect of pityriasis ; the scalp, however, is greasy and not dry. 
There may be itching — generally there is. The disease often dis- 
appears after a time. Its causes are not well made out ; it is said 
to be produced by over-stimulating diet in lymphatic subjects; it 
occurs in either sex, generally about puberty. Xow the fatty 
secretion may vary in consistence and quality in seborrhcea; it 
may be oily, and then represents the acne sebacee fluent e / when it 
forms crusts, the acne sebacee concretee ; and, in a more hardened 
state, plugging the follicles, the acne sebacee corne'e of the French 
writers. These terms sufliciently explain the different appearances 
of the disease. It is usual to describe certain local varieties as 
follows : Seborrhcea capillitii is one : this occurs in infants, and may 
excite eczema. In adults it forms one of the commonest varieties 
of scurf, and in old people it is seen in connexion with senile decay. 
It may also be a part of syphilis. S. faciei, another variety, looks 
like eczema, but there is no discharge, only fatty sebum plates 



ASTEATODES. 487 

covering over a red surface. S. ISTasi and preputii have like char- 
acters. Lastly, there is a S. universalis Neumann describes, which 
is characterized by fatty plates caked on a thin, cachectic, and 
dirty skin (pityriasis tubercentium). I have seen acne of the body 
generally, complicate S. nasi and faciei. In speaking of ichthy- 
osis it will be remembered that I stated that the scaliness or 
horny plates were often made up of a large amount of fatty mat- 
ter. The disease — seborrhoea — occurs as a primary condition ; in 
ichthyosis the fatty caking is but part of a general disorder of the 
skin. But a close resemblance to ichthyosis may be produced by 
seborrhoea ; the naked-eye appearances of the skin may be the 
same, only that the disease is localized, the skin beneath the platy 
scales being naturally healthy. 

Diagnosis. — The disease most likely to be confounded with se- 
borrhoea is eczema, but the latter commences as an inflammatory 
disease ; and in seborrhoea the inflammation or redness of the skin 
is a secondary occurrence. The scales in seborrhoea are not com- 
posed of inflammatory matter. 

Treatment. — The simpler cases of seborrhoea, in infants particu- 
larly, are relieved at once by the free inunction of oil, by which 
the fatty plates are removed, and perhaps not to be re-formed. If, 
however, they show any tendency to re-form, a mild astringent 
ointment made of liquor plumbi, 3 j to 3 j of lard, or a few grains 
of carbonate of lead or oxide of zinc, used night and. morning, suffice 
to prevent their re-formation. In the more marked instances of 
the disease, general in addition to local treatment is required, for 
there is usually some little debility present. I also am of opinion 
that wherever seborrhoea is well marked, save in syphilitic cases, 
cod-liver oil is a very admirable remedy, and specially aids the 
cure of the disease. Some persons are anaemic and require iron, 
and where nervous debility exists a course of arsenic and iron is 
specially needed with the oil. 

Locally, the first point to attend to in these cases is to remove 
the scales, as in the slighter instances of the disease, by the free use 
of simple oil. When the scales have been removed, it is well to 
use some weak mercurial ointment except the surface beneath the 
scales be red and tender, in which case 1 much prefer some sooth- 
ing application, such as a little liquor plumbi rubbed up with adeps. 
The mercurial ointments I refer to are, the nitrate of mercury di- 
luted with six or seven times its bulk of lard or ointment made of 
about three grains of nitric oxide or am monio- chloride of mercury 
to the ounce. A weak sulphur or a bismuth ointment or glyceral 
tannin are by no means ineffective applications. But in some cases 
the disease remains obstinate and then relief may be obtained by 
the soap treatment of Hebra. 

Asteatodes. — This is deficiency of the setaceous secretion. The 
skin appears to be dry and harsh, and this arises from deficient 
action of the sebaceous glands. Asteatodes is seen in hereditary 



488 XANTHELASMA. 

syphilis, and in badly-nourished or uncleanly folk. The treatment 
consists especially in the nse of the bath, oily inflictions, generous 
diet, and tonic remedies, especially cod-liver oil. 

Allosteatodes. — Alteration in the quality of secretion is the 
characteristic of this form of disease. The secretion may be of 
various colours — yellow (seborrhcea flavescens), or black (so-called 
seborrhcea nigricans). 

Seborrhcea flavescens is nothing more than a marked form of 
S. simplex ; indeed is the same as the acne sebacee eoncretee, only 
that the colour of the scaliness is yellowish. The sebaceous matter 
is thick, yellow, forming scales. The disease affects the nose, 
limbs, or trunk; there first exudes an oily transparent fluid, and 
this quickly concretes. The crust may become hard and adherent 
(A. S. comee) and then the part feels and looks like a rasp on a 
small scale, the white epithelial plugs in each sebaceous gland 
standing out over the surface. I have seen this many times about 
the face, especially after that has been acted upon by the sun for 
some time. Sometimes the sebaceous matter poured out is black ; 
this is the stearrhcea nigricans of Wilson. The colour is produced 
by the presence of pigment granules in the cells of the sebaceous 
matter. It is an analogous state to the chromid rosis ; only in the 
latter case the pigment comes with perspiration, in stearrhcea nigri- 
cans with sebaceous matter. The treatment is the same as in the 
simple seborrhcea. 

B. STRUCTURAL DISEASES. 

Xanthelasma (Yitiligoiclea). — Hypertrophy of the epithelial 
lining and adjacent structures of the follicle, with fatty infiltration, 
is sometimes observed, and has been called Vitiligoidea* — a vil- 
lanous term. The disease is as unlike vitiligo as I am. Mr. Wilson 
calls the disease Xanthelasma, because of the yellow laminge which 
characterize it, and this is the best designation. 

The disease may occur in two forms — " either as tubercles, vary- 
ing from the size of a pin's head to that of a large pea, isolated or 
confluent; or secondly, as yellowish patches of irregular outline, 
slightly elevated, and with but little hardness." These are mere 
modifications of one disease, but are termed Y. plana and Y. tu- 
berosa. They may occur together in the same person. The dis- 
ease is seen about the face, the ear, and the limbs and palms of the 
hands. The most common form and seat is a yellowish patching 
about the inner part of the eye ; the disease is symmetrical ; the 
cuticle over the diseased part is unaffected. Kayer figures it at 
PL XXIL, fig. 15, and says, "On the eyelids and in their vicinity 
we occasionally observe little yellowish spots or patches, very much 
like chamois leather in colour, soft to the touch, and slightly 

* See also an article by Drs. Addison and Gull, who described and figured the 
disease in Guy's Hosp. Rep., 2d series, vol. vii. p. 271 ; and vol. viii. p. 149. 



XANTHELASMA. 489 

prominent, without heat or redness and often very symmetrically 
disposed." 

In a case which I recently saw there were about the front of the 
entire arms and the whole outer surface of the lower limbs and 
the buttocks a multitude of tubercles the size of smallish peas ; 
they were raised as much as a pea in height some of them, and 
were reddish in general hue, but studded over with yellowish 
points, and presented such an appearance as syphilitic tubercles 
studded over with large points of pus would give. About the 
elbows were largish plates of the ordinary xanthelasmic colour. I 
will refer directly to the contents of the tubercles. Mr. Hutchinson* 
from an analysis of thirty cases which he has collected concludes 
amono-st other things that 

"Xanthelasma never occurs in children; but it is fairly common in middle and 
senile periods of life. That, in a small proportion of very severe cases, jaundice 
with great enlargement of the liver, is met with. That, when jaundice occurs, it 
almost always precedes the xanthelasmic patches. That the form of jaundice is 
peculiar, the skin becoming of an olive brown, or almost black tint, rather than 
yellow, and the colour being remarkable for its long persistence. That the enlarge- 
ment of the liver may be very great, and that it may subside, and the patient 
regain good health. That in many cases in which there has been no jaundice, 
there is yet the history of frequent and severe attacks of functional disturbance of 
the liver. That xanthelasma occurs more frequently in females than in males, the 
proportion being two to one. That in all cases the xanthelasmic patches appear in 
the eyelids first ; and that not in more than about eight per cent, do they ever 
extend to other parts. That the patches invariably begin near the inner canthus, 
and almost invariably on the left side. That xanthelasmic patches are of little 
value for purposes of prognosis, being usually the evidences of past rather than of 
coming disease. That it seems not improbable that they may result from any cause 
which has induced repeated changes in the nutrition, and especially in the pig- 
mentation of the skin of the eyelids. Thus they occur to those who have been 
liable to have dark areolae round the eyes, whether from 'sick headaches,' ovarian 
disturbance, nervous fatigue, pregnancy, or from any other causes. Hence their 
frequency in ' bilious subjects, 'and in the female sex. That it is probable that of 
the causes mentioned under which the pigmentation of the eyelids may be dis- 
turbed, disorder of the fiver is the most powerful ; hence the fact that the more 
extensive cases are usually associated with hepatic disease." 

Pathological Anatomy — Most authorities regard the disease as 
an hypertrophy of the epithelium of the sebiparous glands ; others 
look upon the disease as due to the deposit of a peculiarly light- 
coloured pigment. 

In a case exhibited to the Pathological Society in June, 1866, by 
Dr. Pavy, a tubercle removed from the back of the little finger 
was submitted to microscopic examination. The deposit pervaded 
the true skin, and occurred in little nodular masses beneath. These 
were exceedingly tough, and consisted of fibrous tissue. On being 
squeezed between the forceps an opalescent juice exuded, which 
was found to contain a large number of fat-granules. The cuticle 
was not involved in the affection. It was argued that independently 
of the result of minute examination, against its being a sebaceous 

* Paper read at the Med. Chirurgical Society, by Mr. Hutchinson. See Lancet, 
March 25, 1871, p. 409 et seq. 



490 



COMEDONES. 



disease was the fact that it occurred, and in a marked manner, on 
the palmar aspect of the hands, where no sebaceous glands existed. 
In my case the same essential changes were found, and Dr. Fagge 
has given evidence to the same effect. 

Cause. — The two last propositions in the series above quoted 
of Mr. Hutchinson's conclusions, give the key perhaps to the 
explanation of the main cause of the disease. Most authorities 
admit the existence of liver disorder prior to the onset of the 
disease. Dr. Frank Smith* probably expressed the views of 
most dermatologists who have studied the matter when he remarks 
that probably " some arrest of biliary excretion occurs ; it is pro- 
longed over months and years, and instead of the fugitive exanthem 
we have the tubercles and plates of vitiligoidea. The skin is not 
the only organ engaged in eliminating the materies morbi / the 
kidneys also separate it in large quanities." 

RETENTION OF SECKETKXN". 

Now this condition of course is always accompanied by change 
in the calibre, and often the structure of the gland, and includes 
comedones, strophulus albidus, molluscum contagiosum, and 
sebaceous cysts. 

The simplest form is seen in the strophulus albidus of children, 
which is nothing more or less than the distension of little fat 
glands by fatty matter. As excessive warmth artificially induced 
in children stimulates the sweat-glands, and produces sudamina, so 
may the fat glands be excited ; and if the secretion of sebum be 
excessive and does not escape, slight distension of the glands occurs. 
Comedones. — Comedones, or grubs, constitute the ordinary black 
specks seen on the face of adults and adolescents, and they are 
produced simply by the retention of sebaceous 
Fig. 92. matter. If slight inflammation be excited, then 
we have acne punctata. The skin in both is thickish, 
greasy ; the secretion is retained and is inspis- 
^|S? sated; the dirt collects at the apex of each little 
ffi ? mD ? aR d forms a black speck or point : the whole 
fig face— for this is the common seat — may be af- 
I fected. The sebaceous matter can be squeezed out 
of each follicle, and then resembles, according to 
popular notion, a little maggot ; the mass is com- 
posed of sebaceous matter, epithelial cells, a num- 
ber of minute hairs, and one or more of a species 
of acarus, called steatozoon (or. acarus) follicu- 
lorum, see fig. 92, after Beale. The spores of a 
fungus, and even puccinia, have been found. 
Comedo is generally regarded as the least expressed 
form of acne. 





* Journal of Cutaneous Medicine, vol. iii., No. 2, Oct. 1869. 



M0LIXSCOI. 491 

The Treatment consists in curing dyspepsial, amenorrhceal, 
leucorrhceal, and such-like conditions, which are often present, 
and tend to favour the occurrence of inflammation ; exhibiting, 
in the lymphatic, iron in combination with saline aperients, and 
cod-liver oil. Locally, shampooing the face, or kneading it, as it 
may be termed- — using very hot fomentation, followed by friction, 
and then certain stimulating and slightly astringent lotions. 
Borax is the best to begin with. Other remedies are bichloride of 
mercury, with almond emulsion, alkaline washes, oxide of zinc 
lotion, weak alum lotion; and, in the later stages, weak hypo- 
chlorite of sulphur ointment. (See Formulary.) 

Sebaceous Cysts. — In some cases the opening of the follicle of 
the gland becomes obliterated, and a cyst forms, filled with 
sebaceous matter, and analogous to the cysts formed in connexion 
with the sweat glands. The simplest form is that of little white 
tumours of roundish shape and opaline aspect, varying in size from 
that of a pin's head to that of a pea, solitary or multiple, and 
generally seated about the eyelids. They contain sebaceous 
matter. It is the acne miliaris of some authors : it differs from 
molluscum to all appearance only by the imperviousness of the 
duct. The treatment consists in turning out the contents and apply- 
ing astringents or nitrate of silver. When the tumours are larger 
and encysted, they are called steatomata. Their most common 
seat is the scalp ; they vary in size, and contain cheesy matter. 

The best mode of treatment is excision. 

Mollusce^i. — It has been usual to describe two forms of mol- 
luscum: but the one is an hypertrophic growth of the fibro- 
cellular tissue : the other a dilatation of the sebaceous gland, caused 
by excessive secretion of sebum and the cell contents of the 
sebaceous gland. This confusion of two different diseases is 
wholly unallowable. I have already described the former variety 
of disease under the head of hypertrophies, as Fibroma. Some 
authors style the disease fibroma molluscum, or molluscum 
fibrosum, but it is better to confine the use of the term molluscum 
to the disease about to be described, the more so as fibroma is a 
sufficiently expressive term for the disease described under that 
term ; the glandular disease about to be described, and at one time 
confounded with fibroma, is Molluscum contagiosum. It commences 
as a little white elevation, like a minute drop of white wax ; this 
enlarges until it attains generally the size of a split pea, but it may 
reach that of a nut. It is of a circular form, firm, white, often 
flattened at the top, where a little ' depression, which marks the 
orifice of the follicle, is seen ; and it is attached by a more or less 
sessile pedicle to the surface. The section shows it to be an 
enlargement and distension of the whole lobules of the sebaceous 
gland. The contents of the little molluscous tumours can be 
squeezed out through the orifice, and consists of soft and whitish 
sebaceous matter. If left alone, these tumours either disappear 



492 



MOLLUSCUM. 



or ulcerate, or remain pretty much in statu quo. The chief seats 
of molluscum are the face, the chest, the arms, the genital parts, 
and the neck. The disease mostly occurs in children, but may be 
seen in adults. The disease is said to be contagious by some ; 
this is denied by others. I have seen a mother and child, and 
a family of children affected in such a way as to be inexplicable 
save by the assumption of the contagiousness of the disease. I 
have no doubt of the contagious nature of the malady. But I 
would further observe that I have seen the disease spring up in 
families, especially in warm weather, in such a way as to give the 
idea of its being epidemic. 

Pathology of Molluscum. — If we examine any of the tumours 

Fig. 93. 




Fig. 1. — Shows the microscopical appearance of a section of a tumour 
of Molluscum contagiosum, as seen by a two-thircl objective, magnifying 
50 diameters. 

Fig. 2. — Shows another portion of the same tumour, as viewed with 
one-fifth objective, magnifying 250 diameters. 

microscopically, we find that the whole sebaceous gland is involved 
and enlarged, the follicle being filled with secretion of a fatty 
character, and the only thing found in the mass are cells, which 
in most cases are similar to those of the epithelium lining, 
save that they are piled together one upon another, and are 
mingled with free nuclei. There are fibrous bands running 
between collections of these cells ; the cells are about from ^ 



ACNE. 493 

to 1 2V0 °^ an i ncn ^ n diameter. They are supposed to be the con- 
tagious agents. I am indebted to Dr. Hilton Fagge for, amongst 
other acts of kindness, permission to quote the accompanying 
figures, which illustrate his paper on the molluscum in the Guy's 
Hospital Reports. 

The Diagnosis. — The disease is easily recognised. The small 
oval or round umbilicated semi-transparent tumours with a central 
opening, from whence sebaceous matter may be squeezed, is un- 
mistakable. In old people, little fibrous outgrowths are to be met 
with about the back and chest, but one may readily see that these 
do not arise from the sebaceous glands ; they are really small 
fibromata or warts. 

The Treatment of Molluscum is simple and effective. In those 
cases where it can be done the contents of the little tumours 
should be squeezed out and nitrate of silver applied to the inside 
of the tumour. If the tumours are small, . the acid nitrate of 
mercury, or potassa fusa solution may be used to them. When 
the tumours are large, their sacs must be removed ; and when the 
tumours are numerous, each must be destroyed by caustic, and an 
astringent lotion used. 

Horns ok Cornua. — When the secretion of the glands is abun- 
dant and pressed together, horns may be formed. 

INFLAMMATORY AFFECTIONS. 
It is generally considered that only one disease ranks here, and 
that is acne ; but I have, it will be remembered, given reasons for 
supposing that furunculus, anthrax, and ecthyma have their 
anatomical seat in or about the sebaceous glands. Their descrip- 
tion, however, will be found under the head of Pustular Diseases. 

ACNE. 

Acne consists of retention of secretion, together with secondary 
inflammation of the sebaceous follicles. At the outset of the 
disease there is simply a collection of sebaceous matter in the 
follicles of the sebaceous glands, and the disease may preserve 
this feature throughout ; there is, in fact, no irritation consequent 
upon the plugging up of the glands. This condition of things, 
the least expressed form of acne, is identical with comedo before 
described ; and it is styled acne jpimctata. The other varieties of 
acne usually made, are only exaggerations of acne punctata, in 
which inflammation of the follicles and parts around is set up. 
They are acme vulgaris, or simplex ; and acne indurata. There 
is also a species of inflammation about the glands characterized by 
the formation of an excessive amount "of connective tissue, 
which is styled acne rosacea. 

Acne vidgaris, or simplex, is acne punctata, with slight peri- 
follicular inflammation superadded. It is observed in the young 
of both sexes, especially about the time of puberty, on the face 



494 ACNE. 

and back ; it appears, first of all, as little hard lumps, rising up, 
so to speak, out of the skin. In severe cases the base is hard and 
the apex pustular. After awhile the pustule scabs over, and 
healing leaves behind a slight cicatrix. 

Acne indurata is acne simplex of an indolent and more or less 
chronic kind ; the separate pustules have a very hard dusky-red 
base; suppuration is scantily evolved; the pustules are painful, 
and there is a feeling of tenseness about the face ; the derma 
generally is congested, thickened and dense; but the disease is 
only an exaggeration of acne vulgaris. 

Acne atrophica and Acne hypertrophic. — These terms have been 
applied — the former to acne spots which are succeeded by atrophy, 
the "latter to acne succeeded by marked hypertrophic growth of 
the connective tissue. The hypertrophy in the latter variety is 
simply the consequence of long-continued congestion, occurring in 
connexion with acne. The tissues become hypertrophied, the 
glands enlarge, the skin is red or violet, rough, uneven, shining, 
and greasy, and little tumours form, which may be sessile or 
pedunculated. It is sometimes connected with intemperance, and 
should be regarded simply as a consequence of acne rosacea rather 
than an independent condition. 

Syphilitic acne has been described (p. 289). 
Morbid Anatomy of the above varieties. — The first stage in the 
morbid process by which an acne pustule is produced consists of 
engorgement of the vessels of the hair follicles and sebaceous 
glands. This is followed by the infiltration of inflammatory pro- 
ducts about the sheaths of the hair and the connective tissue 
surrounding them, together with the formation of pus in these 
parts. This pus then makes its way to the surface, probably 
along the sheath of the hair, and collects under the upper layers 
of the epidermic cells. When the pus escapes the acne spot may 
gradually subside, or the hypersemia continuing, the connective 
• tissue hypertrophies, forming the hard base of acne indurata. In 
acne indurata, the hypertrophous growth of tissue is conjoined to 
perifollicular suppuration — the former being most marked, the 
latter not to any great extent as a rule. There are no hard and 
fast lines between the features of these several varieties. Upon 
the same face or back may very commonly be observed here 
comedones ; there acne simplex (inflamed comedones) ; and there 
indurated pustules of acne (acne indurata). 

Acne Rosacea. — There seems to be a great deal of discomfort 
produced in the minds of dermatologists in regard to the position 
usually assigned to this disease in the nosologies of different 
writers. But, after all, it is not of much consequence whether we 
class acne rosacea with acne or chronic inflammations of the skin. 
The disease is a composite affair. It is a chronic inflammation of 
the face made up of acne spots, periglandular inflammation, 
erythema and new growths of connective tissue growing inde- 



ACNE. 495 

pendently of the glands. The first stage consists in congestion 
of the face, and more or less dilatation of certain capillaries. 
Certain points of the papillary layer become hypergemic, and 
certain of the glands are similarly affected, so that acne spots are 
produced, an excessive amount of sebum is often secreted, and the 
skin feels greasy (seborrhoea). The general surface of the skin 
of the face is more or less congested. In the next stage, as 
the consecpience of the continued inflammation, the connective 
tissue around and about the glands hypertrophies — that is to 
say, the acne spots become indurated and hard whilst the in- 
dependent non-glandular papules become more marked. The 
colour of the redness is bright red, the vessels become varicose 
and ramble freely over the surface of the diseased parts ; suppura- 
tion is not very marked, but the integument generally is thickened 
as a consequence of the general congestion. Xow this disease is 
rarely seen in the young. It occurs in women of middle age who 
suffer from uterine troubles, and attacks the nose by preference. 
The disease is aggravated by trouble, by stimulating food, by 
exposure, by dyspepsia, and by alcoholic drinks. 

Tar Acne I have already referred to, in speaking of medicinal 
rashes. 

Etiology. — There ought to be little difficulty in arriving at a 
satisfactory conclusion as to the chief conditions which lead to the 
development of acne for the simple reason that the disease is so 
abundantly common, at least in England, as to furnish an exhaust- 
less supply of material for observation on this point. The state- 
ment that acne is due to the accumulation of sebaceous secretion 
in the glands and perifollicular inflammation excited thereby is 
satisfactory as far as it goes, but the reader naturally desires to 
know what leads to the accumulation of sebum, and what are the 
influences that lead to the varying character and degree of the 
perifollicular inflammation. I will mention some of the causes. 
In the first place it must be remembered that the circulation of 
the face is sensitive to irritants ; it is liable to great fluctuation ; 
it is very active. These states are acted upon by external, and 
not only external, but various internal agencies ; and nothing is 
more probable than that some derangement of the vascular supply 
will frequently take place. Then the glands are particularly 
well developed in the very situations in which acne is wont to 
occur — the face for instance — they are therefore likely to become 
functionally deranged. All debilitating causes, all local causes of 
irritation and disorders of those organs which have a reflex rela- 
tion with the face, want of cleanliness, cold winds, the use of 
cosmetics, and many other things may induce glandular conges- 
tion, and so acme. 

But in addition to this, acne occurs at a time when the hair 
follicles and their related sebaceous glands are physiologically 
active — that is to say, at puberty, when there is a great develop- 



496 ACNE. 

ment of hair over the body, and naturally much activity of the seba- 
ceous glands. Whenever a portion of the body is physiologically 
active it is likely to become disordered if the general or local con- 
dition of nutrition is deranged or defective. Physiological activity of 
the hair follicles implies activity of the blood-vessels and of nerve 
supply ; and if there be local or general debility, what is termed 
"sluggish circulation," leading to congestion, may occur: and 
the action of external irritants, heat, cold, and the like, will 
operate more effectively as an excitant of congestion than under 
ordinary circumstances. Moreover, under the same circum- 
stances, certain disordered conditions of internal organs, ex. stomach, 
more readily intensify the congestion by reflex action, and hence 
also it is that uterine and stomach and mental troubles aggravate 
acne. But there is something more than this to be said. In 
some persons the sebaceous glands seem naturally to be specially 
active. The skins of these persons are greasy/ the secretion of 
sebum is freer than in others, and it may be different perhaps in 
physical characters, and when additionally excited the glands may 
readily be blocked with the sebum, and so produce comedo. Now 
it has always appeared to me that lymphatic and strumous 
subjects are prone to acne. At a time then when the glands are 
physiologically active, the gland function is apt to be disturbed ; 
they become congested, and the congestion may be excited, or 
at least it is intensified by local irritants, by reflected irritation 
from the stomach, or mental and uterine disease. In most cases 
the secretion of sebum blocks the gland duct, and the gland 
inflames as the result of the blocking up of its outlet, and perhaps 
the decomposition of the retained contents. These influences will 
of course only account for the plugging ivp of the glands, and a 
certain amount of congestion of them. The intensity of the 
inflammation, or at least of its effects as shown by the amount of 
pus production, and the degree and exact character of the subse- 
quent hyperplasia, will depend upon the constitutional condition 
of the individual. In fairly vigorous subjects the acne will be 
slight, and if all goes well the inflammatory symptoms will sub- 
side without leaving any remnants of mischief behind. If the sub- 
jects in whom acne occurs are very dyspeptic, and if the dyspepsia, 
by its severity and long-continuance, (or if uterine mischief) cause 
much intensification of the hypersemia, say of the face, and particu- 
larly if the patient be weak, the disease will be chronic, and the 
chronic inflammatory thickening about the glands marked (acne 
inclurata). If the subject be strumous there will be probably 
much implication of the connective tissue about the glands, free 
pus production, and the disease will probably leave behind it 
much pitting (atrophy) after the removal of the large indolent, 
livid swelling that forms about the glands. 

The above considerations bear directly upon the treatment of 
acne, and unless they are taken into account the practitioner will 



ACNE. 497 

certainly not be so successful in, as lie might be, his treatment of 
acne. 

Treatment. — Acne is an inflammatory disease set up by irritation ; 
and it must be cured by removing the cause of irritation, and by 
soothing the irritated part. I will set forth in order as shortly as 
I may be able the kind of treatments the different forms of acne 
require. 

Looking upon acne as a whole, the object of the practitioner 
should be to prevent comedo or acne punctata from passing on to 
acne vulgaris, by getting rid of the obstruction in the glands, and 
checking the hypersemic condition ; in acne indurata to diminish 
hyperemia, and promote the absorption of inflammatory products ; 
and in acne rosacea to check hyperemia, and to destroy the new 
growth of connective tissue. Now it will be observed how much 
stress I lay upon checking hyperemia, and this is to be effected 
not in one, but in various ways, since the causes of its existence are 
various. Hyperemia may be controlled by internal remedies, by 
local remedies, or by removing conditions that by reflex action 
give rise to its continuance. But its disappearance may always 
be helped out by excluding the air from the face as much as 
possible. But I proceed to give further details. 

The treatment of comedo or acne punctata has been dealt with. 
In acne vulgaris or simplex the practitioner generally has to deal 
with individuals who are debilitated, oftentimes with those who 
have neglected proper personal hygiene, or who have been working 
in ill-ventilated, stuffy, and heated workrooms ; or who have lived 
on insufficient or too highly seasoned food : or those who whilst 
their excretory organs have been acting sluggishly have been 
taking a full diet ; but, above all, with persons who suffer from 
atonic dyspepsia. In a word, with persons whose debility interferes 
with the proper performance of the gland function at a time 
when it is physiologically active, and whose dyspepsia causes con- 
gestion of the face, or the particular part of it physiologically 
active. I invariably under these circumstances begin by pre- 
scribing an alterative pill, and such a mixture as is given in ISTo. 163 
in the Formulary, a dose of which is to be taken an hour or so 
before each meal, the mixture being continued until the dyspepsial 
symptoms have disappeared, when I give a course of Yals water 
with the particular tonic suited to the condition of the individual 
I am treating. Oftentimes it is an arsenic pill (see Formula 182) 
or cod-liver oil or iron. Locally I interdict the use of all soap in 
the early stages, direct the face to be bathed with hot water night 
and morning, and the lotion (Formula No. 118) to be well shaken 
up, and applied with a sponge, and allowed to dry on, the super- 
abundant powder being wiped or brushed off with a soft handker- 
chief. If the disease becomes indolent, stimulants may be used, 
none are better than a little weak sulphur ointment. Some prefer 
32 



498 ACNE. 

such remedies as are given in Formulae 93, 95, 101, 102, 103, 
105, 106, 125. 

In acne indurata the same line of treatment is to be pursued 
at the outset, until the active congestion is passed. Where 
debility with constipation exists, and the face is very hypersemic, 
No. 159 is a very excellent mixture for internal use. When the 
disease has become more or less indolent, it is then that stimulants 
and revulsives may be applied, and indeed the local is the more 
important treatment in such cases. Fomentation with very hot 
water night and morning is always advisable, and the indolent 
and indurated spots may be touched lightly with acid nitrate of 
mercury every few clays to hasten their disappearance, whilst a 
weak ointment of iodide of sulphur or sulphate of zinc, or hyper- 
chlorite of sulphur ointment, may be used in the interim. I do not 
advise, nor do I use, biniodide of mercury ointment, and the like 
powerful remedies advocated by some writers. In acne rosacea it 
is of the utmost importance to attend to the state of the uterine 
functions, and also that of the stomach. I invariably employ 
soothing remedies in the early stage, and wait until the hyperaemia 
has lessened in activity or amount until I adopt measures to 
destroy the newly formed connective tissue. Attention to diet and 
good hygiene are eminently essential in regard to acne rosacea. 
If there be varicose vessels, they may be cut across, as recommended 
by Westerton. The incisions should be never deeper than 2"' ; 
and the subsequent use of cold water will stay the bleeding, 
collodion being subsequently used to contract and heal the incisions. 
I have generally seen acids, and especially pepsin, given internally 
do much good. Much lias been said with regard to the efficacy 
of the ioclo-chloride of mercury in acne rosacea. It should be 
used in the proportion of gr. v — xv to § j of lard ; it requires 
care, as it produces a good deal of irritation. It is a preferable plan 
to touch the apices of the pustules with acid nitrate of mercury ; 
this causes their absorption, often very rapidly. The tincture 
of horseradish is also said to act very efficiently, but I have no 
experience of its use. See also Formulae 114, 115, 116, 151 to 
172, 174. 

The diet of all forms of acne should be unstimulating ; and if 
the patient be dyspeptic, he or she should avoid sugar, pastry, 
seasoned dishes, and beer, spirits, and certainly sherry and 
port wine. 

The after-treatment of acne consists in the exhibition of a 
general course of tonics, the mineral acids, or iron, or cod-liver 
oil, or arsenic, as seems best suited to the individual case in hand. 



DISEASES OF THE NAILS. 499 



DISEASES OF THE NAILS. 

The nails become diseased under a variety of conditions. The 
changes which they undergo may form part only, of a disease which 
affects the general system or the surface of the skin, or the disease 
of the nail may be the sole morbid state present in a patient. I 
will briefly refer to the several changes which the nails undergo 
under these different circumstances. 

The nails become peculiarly rounded in aneurism, cyanosis, 
chronic inflammations of the chest, and phthisis. They are like- 
wise disordered in pityriasis rubra (see p. 253), lichen ruber (see 
p. 144), psoriasis (see p. 259) ; and the changes they undergo in con- 
nexion with these diseases, I have already spoken of in treating of 
the latter. 

In syphilis and leprosy the nails also become diseased (see 
p. 295, and p. 310), in connexion with the tinea again the nails 
suffer change from the attack of certain fungi upon them (see 
Onychomycosis, p. 466). 

Onychia is the term applied to inflammation of the matrix of 
the nail. The inflammation is generally erysipelatous in character, 
It may be primary and idiopathic, or secondary, but also trau- 
matic. The early symptoms are sense of heat, pain and throbbing 
with redness just around the base of the nail of erysipelatous aspect. 
These increase, the surface gets livid, the part beneath the nail 
inflamed, and assumes a cloudy and often a sanious appearance, in 
consequence of the effusion of blood ; the nail loosens, becomes 
soddened, opaque, and thickened ; and from beneath its surface 
oozes out a nasty dirty fluid. The nail often falls off by-and-by, 
leaving behind a very tender pultaceous-looking raw surface, which 
readily bleeds. Two courses may now be taken. The part may 
ulcerate, the finger inflame, the bone necrose more or less, and 
phlegmonous inflammation attack the arm : or an attempt at 
repair is made, after awhile a new nail is produced, which is short 
and generally stumpy. The treatment consists of local blood- 
letting, warm fomentations, removal of the nail and other dead 
structures ; the use also of astringent lotions, good and generous 
diet and bark, with acid or ammonia internally. Syphilitic onychia 
has been noticed elsewhere (see p. 295). 

In-growing of the toe-nail is easily cured by softening the nail, 
and then scraping off as much as possible, so as to thin it in the 
middle. 

The practitioner will sometimes meet with a " corn " underneath 
the nail. It is a painful affection and may require the application 
of caustics. 



CHAPTER XXII. 

DISEASES OF THE HAIR AND HAIR FOLLICLE. 

DISEASES OF THE HAIR. 

Diseases of the hair may be divided into those of Augmented and 
Diminished Formation, Abnormal Direction, and Alteration in 
Physical Aspect. 

Augmented groicth may be congenital and of varying- extent, from small localized 
growths, such as little hairy moles, tc the extensive tracts covering more or less 
of the body, as in the " hairy man " described by Mr. Crawfurd. Stimulation has 
a tendency to augment the growth of hair, if the formative power is normal. 
During convalescence a freakish, reactionary growth, in odd and unusual places, 
sometimes takes place. 

Diminished formation of hair is partial or general, comparative (thinning) or 
absolute (alopecia). It may be congenital, accidental, or normal (senile). Dimi- 
nished formation of hair may be represented in its different phases of occurrence 
as follows : — 

1. Congenital— (a) partial, (b) general. This is a rare form of disease. Gene- 

rally downy hairs stud the surface and prove the existence of bulbs, 
though in an inactive state. 

2. Accidental — (a) partial, as in tinea decalvans and other parasitic diseases ; in 

cases of wounds, direct injury, and the like ; (b) general, arising from 
such causes as lower the vital tone — e.g., fevers, syphilis, amemia, gout, 
rheumatism, neuralgia, fast living, great study, violent emotions, dys- 
pepsia, want of cleanliness, over-purgation, local eruptive diseases, wasting 
of subcutaneous fat, atrophic state of the peripheral nerves, morphcea (?), 
and lastly, physiological states — e. g. , hereditary peculiarity, pregnancy, 
seasonal shedding, deficiency of formative force inherent in the system, 
and failure of the mutual relations of parts. 

3. Normal, as the shedding of the lanugo, and the loss of hair in old age 

(calvities). 
Alopecia. — When the hair is lost entirely from a part, this is called alopecia, or 
baldness. Parasitic disease and atrophy of the bulbs are the most usual causes of 
localized baldness ; syphilis, violent emotion, atrophy of the scalp (?), and senility, 
are most efficient in producing an absolute or a gnat amount of baldness. The 
other conditions noticed above usually give rise to thinning, not absolute loss or 
baldness. The total loss of hair is sometimes seen in early life. I have had young 
boys and girls under observation who have not a vestige of hair on the scalp. Now 
in some instances of complete loss, the baldness has commenced at one spot and 
travelled over the scalp. In other cases the disease commences as a general 
thinning; " handfuls" of hair have "come out" and suddenly the whole has been lost. 
Various theories have been suggested. Von Barensprung believes that the cause 
is a failure in the nerve-power. It is clear that the formative power suddenly 
fails, for in the early condition the follicles are distinct, and the skin is normal. 
It is true that it presently becomes thinned, hard, white, shining, insensible 
somewhat, and the follicles waste ; but these changes are sometimes the necessary 
consequence of the inactivity of the hair-forming apparatus,, and not the cause of 
the loss of hair. It appears to me that in some of these cases the hair dies from 
want of nutritive pabulum, as in syphilis ; in others, in consequence of the cessa- 
tion of the normal reproductive function of the formative apparatus. The hair 
comrs to its natural period of existence, and no attempt is made to reform it. 



ALOPECIA. 501 

Violent grief, great mental labour, and anxiety, are determining causes of this 
form of baldness. 

Alopecia circumscripta. — The localized alopecia, alopecia areata, or circumscripta, 
is common. It is different from tinea decalvans, though the naked eye characters 
are the same. The hairs fall out from a certain spot, leaving that spot bare of its 
hairs, and the tissues of the part white, shining like alabaster. Many theories 
have been invented to explain this condition. The hairs which come out are found 
to be tapered and atrophied at their roots, and devoid of their root sheaths, and 
that is all that is certainly known about the matter at present. 

Fragility of the hair, seen oftentimes about the beard, is explained by the attack 
of fungi, or by such causes as lead to insufficient nourishment of the hair, whereby 
its fibres are ill-formed, and tend to undergo degeneration. (See also p. 459.) 

Senile baldness, or calvities, is due to an atrophy of the structures generally; it 
commences on the crown of the head, the hair first turning gray ; the scalp is dry, 
thinned, loses its subcutaneous fat, and the follicles become indistinct. In some 
people this change takes place at an early age ; it is either an hereditary or physio- 
logical peculiarity. 

General thinning of the hair, it is easy to understand, is most likely to occur 
under conditions which lower the vital energy of the patient. The scalp generally 
is scurfy and dry. This is in all probability due to the sluggish action which goes 
on. The usual sebaceous matter is not secreted; the follicles become choked by 
retained fatty and epithelial matter, and the formation of the hair is interfered 
with. This is also the case in eruptive disease and in syphilis. 

The loss of hair in all these cases is an evidence of the working of some debi- 
litating cause ; it is not remediable to the most perfect extent without the use of 
general remedies — not by the employment of local stimulation. 

The hair in cases of thinning and baldness is often dry, brittle (crisp), and 
twisted or split up. This results from the peculiar absence of moisture ; in its 
turn from the diminished activity of the circulation of the scalp ; in its turn again, 
from the general debility of the system. 

The various other alterations in physical aspect come under the head of Parasitic 
Disease. 

The Diagnosis. — Senile baldness commences with the hair becoming gray; it 
occurs of course in old people, at the vertex of the scalp first of all. The struc- 
tures generally waste ; there is little subcutaneous fat ; the follicles are indistinct ; 
the circulation is diminished, and the scalp is white, thin, and shining. 

Alopecia from parasitic disease occurs in the young chiefly, and is preceded by 
signs of local irritation. It commences not at the vertex, but at the side of the 
head generally ; the hair is not grey, the scalp is natural ; it is not white, thin, and 
shining, but the follicles are distinctly visible and the circulation is always pretty 
active. In some cases there are peculiar features present, in consequence of the 
rapid and free growth of the fungus — e. g., favus, tinea tonsurans. Parasitic 
disease and atrophy give rise to partial loss ; debilitating causes to general thin- 
ning ; syphilis sometimes to general loss, but mostly temporary thinning. 

The Treatment. — In the cases of total loss, much good may oftentimes be done. 
In the first place, all syphilitic taints require detection and specific treatment ; the 
hair will assuredly grow if a syphihtic taint be treated. Then debility of all kinds 
must be removed ; and this is a matter of some considerable nicety, rules for 
which cannot be laid down. It is customary to give arsenic in these cases, and it 
is requisite that the student should know that one of its special actions is supposed 
to be the promotion of the re-growth of the hair. I prefer to treat the patients not 
by specifics but on general principles. With regard to the cases of general thinning 
dyspepsia has appeared to me to be a very frequent source of evil ; it has assumed 
too a most determined and inveterate form, resisting acids, alkalies, bitters. Iron 
and tincture of nux vomica are useful tonics in the ''nervous" cases. With regard 
to local measures : In the cases of absolute loss, which occur from trouble, or 
rather a failure of the reproductive function of hair-forming apparatus, local stimu- 
lation is the sine qua non whenever any downy hairs are visible ; if these be absent, 
the scalp atrophied from disease, and white and shining, little good will be done, 
though I have succeeded even here. Repeated blistering must be adopted, and 
stimulating washes used. If there be oedema, or any tension, though the follicles 
are distinct, tincture of iodine applied over diseased parts every two or three days 
is of service. Shaving the downy-haired scalp is also beneficial. Mne out of 
ten affirm that this does harm. I know to the contrary ; it should be done once a 



502 sycosis. 

fortnight regularly for a ■while. In the case of general thinning, the plan of stimu- 
lation requires modification. The general state of nutrition is below par ; and 
hence the local also. The scalp is not healthy ; it is dry, scurfy, irritable. We 
should first of all try and get it into a soft and cleanly condition by frequent 
ablution, the use of glycerine and lime-water, or olive-oil and lime-water, used 
night and morning. Then we may recommeud local warm vapour douches, with 
gentle friction and galvanism. When the system is under the influence of tonics, 
we may employ local stimulation with the best results. Some teach that greasy 
applications should be avoided. As a rule, this is good advice. Certain ordinary 
pomades, cosmetics, and the like, on account of their very rancidity, do harm ; the 
olive-oil and lime-water compound is not open to this objection. Tincture of nux 
vomica I have found the most efficient local remedy, in combination with distilled 
vinegar, and tincture of cantharides. 

When thinning of the hair is the result of eruptive disease, it is due to debility, 
and must be treated upon ordinary principles. 

DISEASES OF THE HAIR FOLLICLES. 

Certain disorders connected with the hair follicle, or rather the 
structures contained within it or attached to it, have been con- 
sidered in speaking of diseases of the hair, diseases of the sebaceous 
f lands, certain inflammatory affections, and parasitic diseases. But 
have as yet not spoken of one independent morbid state of the 
actual hair follicle itself — viz., sycosis, or inflammation of the hair 
follicle. 

Sycosis. — As I have explained, under the head of tinea sycosis, 
inflammation of the hair follicles of the beard may be produced 
by a parasitic or a non-parasitic cause. I have already described 
the' parasitic variety under the term tinea sycosis (see p. 457). The 
disease, the features, course, and treatment of which I am about 
to detail, is a simple, non-parasitic parenchymatous inflammation 
of the hair follicles, and it is styled simply sycosis. 

Sycosis is usually confined to the hair follicles of the beard and 
the whiskers, but it may occur in other hairy parts. It begins by 
the development of pimples, some raised, some not raised above 
the level of the skin, but which are all seen to be situated at the 
hair follicles, for a hair pierces the centre of each little lump. 
These pimples quickly pustulate, even from their earliest existence, 
and are accompanied by more or less inflammatory swelling of the 
perifollicular tissue ; this swelling may be very marked and pain- 
ful. This state of things may exist over a limited part of the face 
for some time, or it may gradually spread and involve both sides 
and the whole beard and whisker areas. 

The appearances of sycosis differ much after what may be 
termed the acute stage is passed. The inflammation may subside 
and be limited to a few isolated and tuberculated pustules here 
and there. In other cases the skin of the beard and whiskers in 
different parts is reddened ; it feels harsh and throws ofl a good 
deal of scurf; there being here and there a pustule or two. In 
some instances the disease quiesces for a time, or the parts 
attacked thicken very considerably and become indurated, so that 
the surface is generally raised, from the chronic inflammatory 



sycosis. 503 

thickening and studded over with pustules and suppurating tuber- 
cles (inflamed follicles). If there be much pus formation dis- 
tinct crusts may form over the surface. In some cases, especially 
those in which there is much induration, subsequent atrophy of 
the tissues occurs, and a thin scar-like surface, such as is left after 
a superficial lupus has disappeared, results ; in fact, the disease, 
so far as its results in these cases is concerned, seems very like a 
lupus, only its history and concomitants show that it was originally 
a p'ustular disease of the hair follicles. 

The state of the hairs is an important thing to notice in the early 
stages ; the root is enlarged and surrounded by pus, and this condi- 
tion, less marked, is found in chronic cases : but the hairs are not 
loosened as the rule, and not rendered brittle as in parasitic disease. 
The suppuration may loosen one here and there, but there is no 
fungus attacking them to alter them texturallv. 

I have repeatedly noticed a condition of the head in connexion 
with sycosis very much like that which exists about the beard, and 
in conjunction with disease of the beard. The upper lip may also 
be the seat of the disease. 

Perhaps no cases are more troublesome than those of sycosis. 
My out-patients' room at University College Hospital is never free 
fr^m them. The cases in which the freest suppuration occurs are, 
I think, generally developed in strumous subjects. The general 
health of sycotic patients I have not found to be good. They are 
pale, weak, and often overworked. 

Nature of the Disease. — It is a simple inflammation of the 
follicles of the beard, with the ordinary results of long-continued 
congestion. But it seems that the result of the inflammatory in- 
filtration may destroy the normal texture, and so lead to more or 
less atrophy. 

Causes. — At present nothing is known of the cause of sycosis. 
Any local irritant, such as the continued play of heat upon the 
skin of the face, as in the case of those who work in hot rooms, or 
who shift during their work from hot to cold rooms, and vice versa, 
will set up inflammation of the hair follicles in those who are out 
of health. Irritation by the razor in shaving will act similarly ; 
but further than this I have nothing to remark, except that diathesis 
considerably influences the disease, for in syphilitic and strumous 
subjects the disease is abominably obstinate. 

Diagnosis. — The disease may be mistaken for lupus — this I have 
already noticed. It may be confounded with tinea sycosis, but in 
that disease the hairs are texturallv altered and loosened, and the 
parasite can be detected. 

Treatment. — First as regards general remedies. In the acute 
state gouty and dyspeptic tendencies must be recognised, and the 
patient treated accordingly, since gout and dyspepsia aggravate 
the disease. The diet should be most carefully regulated. 

It is further important that aperients should if necessary be 



504: SYCOSIS. 

given, whilst stimulants, if they "heat" the system, be disallowed. 
Locally, the removal of crusts by oil, or poulticing the part once 
or twice, and applying a lead and opiate lotion, allays the inflam- 
mation in the first instance. The time for active treatment is 
when the irritative stage of the disease has passed. Then tonics ; 
iron, if anosmia be present : cod-liver oil and the like if the patient 
be strumous : or the mineral acids and bitters if he be atonically 
dyspeptic may be given, and some very weak mercurial ointment 
(citrine ointment, 1 part to 8 of lard) applied after hot fomen- 
tations night and morning. Epilation mostly fails to do good in 
my hands, and I now only employ it very rarely indeed. When 
there is much inflammatory thickeniug, however, there is one 
remedy that now I always give, and that is Donovan's solution. I 
have come to the conclusion that it is the only internal remedy of 
much use in sycosis ; but it must be employed at the right time, 
and in conjunction with tonics appropriate to the general condition 
of the individual. The practitioner may combine with the inter- 
nal exhibition of the Donovan, the local application of mercurial 
plaster ; but I have found nothing so good locally as hot fomenta- 
tions and weak citrine ointment. 



FORMULAE. 

MINERAL WATERS IN SKIN DISEASES. 

The dermatologist may very frequently considerably forward the cure of skin 
disease by the exhibition of certain mineral waters. But it is rather with a view 
to meet certain constitutional peculiarities and to influence the skin indirectly, 
than to directly remove cutaneous troubles, that such waters are to be employed. 
Personally I only employ purgative, akaline, and iron waters, and the water of 
the Woodhall Spa. 

PURGATIVE WATERS. 

The most convenient for general use, as well as the most efficacious amongst the 
purgative waters, are those of Pullna and Friedrichshall. 

Pullna. — This contains sulphate of magnesia in good amount, besides sulphate 
of soda and chlorides of sodium and magnesium. The dose of this water is about 
a wineglassful mixed with an equal quantity of hot water : and this dose should be 
taken early in the morning before breakfast. 

Use. — In the hyperseniic and inflammatory diseases of the skin where the system 
is loaded by retained excreta, the result of constipation or dyspepsia, or torpid 
liver action. 

Friedrjchshall. — This has much the same properties as the last mentioned 
water. It is, however, much less irritating than the Pullna. It may be given 
under the same circumstances as the latter, in doses of half a tumblerful, mixed 
with warm water, one, two, or more times a day. 

ALKALINE WATERS. 

Vals. — I am in the habit of using the Vals waters almost exclusively when it is 
desirable to prescribe alkalies. These waters contain chiefly bicarbonate of soda. 
There are six springs — the Precieuse and Desiree, laxative ; the Magdeline, Rigo- 
lette and Dominique, tonic ; and the St. Jean, sedative. The Precieuse is the most 
useful, according to my experience. 

Use. — I use these waters in dyspeptic cases in which there is a very acid condition 
of urine ; or when I wish to give alkalies in connexion with tonics ; or as conve- 
nient diuretics. They are serviceable therefore in chronic eczema, psoriasis, acne, 
and the erythemata — in gouty, rheumatic, and dyspeptic subjects. 

The Dose. — I usually prescribe three quarters or a full tumblerful twice a day, 
and the water may be taken with wine or spirits at meals ; or one dose may be 
taken at bedtime, and the other at the midday meal. If these waters act too freely 
on the kidneys, the quantity given must be diminished. The urine must always 
be watched for alkalinity. 

St. GalmiePv. — This water contains the bicarbonate of soda and potash, magnesia 
and lime, sulphate of soda, &c, and much oxygen. It is good for dyspeptics. 

Carlsbad (Sprudel). — This water contains sulphate and carbonate of soda, with 
chloride of sodium, &c. It may be given in doses of from two to four large 
tumblerfuls a day in connexion with cutaneous diseases complicated by uterine 
disorder, as for instance acne rosacea. 

FERRUGINOUS WATERS. 

These waters are useful where persons are anasmic, and have a weak languid 
circulation, or in cases in which there is amenorrhcea. Some of them may be taken 
with meals. 



506 SPAS OF USE IN SKIN DISEASES. 

Des Dames (Vichy). — This is a mild water containing- iron, and is adapted to 
weak and nervous females. The water may be taken in doses of a tumblerful or 
so twice a day. 

Spa. — This is a good water, especially if obtained from the Pouhon spring. The 
water contains bicarbonates of iron, lime, magnesia, soda, &c. It is therefore an 
alkaline ferruginous water, and may be given in connexion with skin eruptions 
complicated by anaemia and dyspepsia, but I have not much experience of its use. 
The dose is from one to four tumblerfuls a day. 

Pyrmont. — This contains carbonates of iron, lime, magnesia, with a certain 
amount of sulphate of magnesia and chlorides of sodium and magnesium. It is 
useful under the same conditions as the last. The dose is eight or ten ounces, 
which may be taken with wine at meals two or three times a day. 

Schwalbacii (source Weinbrunnen) is also an excellent water, and may be used 
as the latter. 

SPAS OF USE IN SKIN DISEASES. 

A visit to foreign spas, which is usually made between May and October, in 
search of relief from cutaneous trouble, is a common occurrence now-a-days. I 
doubt not, however, that the relief obtained is oftentimes not directly due to the 
baths taken and the water drank at these spas, but to the fairly quiet life led at 
most of the spas, the regularity of living, the change of scene, and the freedom 
from the " late hours," " the heavy dinners," and the like, which form so great an 
item in the life of a London season. Not that I am at all disposed to deny that 
much good may be done by a visit to foreign spas. On the contrary, I believe 
there is a time in most skin diseases — it is generally at the time the patient is 
getting towards convalescence— when a visit to a Continental or English Spa will 
do great things for him. It is chiefly with a view to get rid of gouty and dyspeptic 
tendencies that I advise patients to go to the various spas ; or to renovate their 
constitutional vigour after a long course of mineral medicine ; or for the relief of 
obstinate anasmia ; or the removal of specific cachexia. The following is a list of 
the different spas to which patients may be sent. The diseases for which the 
waters of particular spas are appropriate are also stated. 

A. Foreign : — 

L fSzbrunn.v. :':;.::*.:::::. 1 For eczema and p ruri ^°- 

2. Wiesbaden [ Ulcers and chronic skin diseases, with abdo- 

Bourbonne les Bains ) minal plethora. 

3 ' p u \i^ ichshaU I Scrofulous skin diseases. 

TC >f^ f Eczema in the early stages, and pityriasis. 

5. Kreuznach ) Lupus, sycosis, lichen, ichthyosis, scrofulous 

Krankenheil ) ulcers. 

6. Leuk (Loucche) Eczema, psoriasis, and all chronic skin diseases. 

7. Wildbad | 

Gastein I Prurigo, psoriasis, and lichen, where there is 

Pf aeffers \ nervous debility. 

Teplitz J 

8. Spa 

Schwalbach I Skin diseases connected with or owing to 

Pyrmont ) anasmia. 

Franzensbad 

9. Aix-la-Chapelle 

Baden (near Vienna) 

Baden (in Switzerland) . 
Aix-les-Bains I 

Bagneres du Luchon I All sulphurous waters, useful in acne, pity- 
Bareges j riasis, psoriasis, prurigo, sycosis. 

St. Sauveur 

Eaux Bonnes I 



Nenndorf I 

Sandefjord (Norway) J 



BATHS m SKIN DISEASES. 507 

B. English Waters :— 

1. Sulphurous. — Harrogate, Moffat. Cheltenham (sulphur spring). The former 

is suited especially to eczematous disease in gouty and rheumatic subjects. 

2. Saline. — Cheltenham, Buxton, Bath, Scarborough, Leamington (New and 

Old Bath). 

3. Chalybeate. — Tunbridge, Cheltenham (chalybeate), Brighton. I think very 

highly of the iron water of Tunbridge "Wells. I have seen this do much 
benefit to anaemic subjects suffering from chronic skin diseases. 

4. Bromo-iodine.— Purton in North Wilts, temperature 58£° F., useful in stru- 

mous subjects ; and the Woodhall Spa in Lincolnshire. The latter is 

situated midway between Boston aud Lincoln. It is one of the very few 

spas in this country which contain in any medicinal quantity those potent 

and most beneficial agents, bromine and iodine. Amongst the Continental 

mineral waters, it most closely resembles that of the celebrated Kreuznach 

Spa, to which invalids of a certain class resort from nearly all parts of the 

world. It differs from and is superior to the waters of that spa in the 

very much larger quantities of bromine and iodine present in the former, 

and which are stated to be some three or four times as great. 

The bromo-iodine water of the Woodhall Spa is a very powerful remedial agent, 

especially valuable in cases of scrofula, lupus, some cases of syphilis, and of psoriasis, 

especially in rheumatic subjects. The water of the spa at W T oodhall contains a 

proportion of 5-J grains of iodine to 10 gallons ; and 20i grains of bromine in 10 

quarts. 

BATHS IN SKIN DISEASES. 
The use of baths for the alleviation of pruritus in skin diseases, for removing 
scaliness, for promoting the absorption of inflammatory or specific products, and 
the destruction of parasites of different kinds is coming, I rejoice to say, into 
more common practice. My own opinion is, that skin diseases should be much 
more systematically treated by baths than they are. In describing the various 
diseases of the 6kin, I have indicated under what conditions the several kinds of 
baths should be used. 1 have now to give some further details as to the composi- 
tion and exact mode of using these baths. 

1. Simple Vapour Baths. 

a. The Brick Vapour Bath. — Those who have not the appliances for giving a proper 
vapour bath will find Mr. Grantham's a simple mode of applying steam vapour to 
the body. His directions are as follows: — "Boil two gallons of water; at the 
same time put into the fire half a brick, which must be heated to redness ; have 
a cane-bottomed chair and a hot bath to the feet, with a large blanket in the 
room ; put the boiling water into an earthen pan, and place it under the chair : 
then put the red-hot brick into the pan. The patient is to be seated on the chair 
in a state of nudity, with the feet in the foot-bath, and then to be covered, except- 
ing the head and face, by the blanket. By these means the steam is kept up on 
the surface of the body for the space of fifteen or twenty minutes ; after which the 
patient is to be well dried and retire to a warm room, or be placed between the 
blankets." 

b. A Modified Plan for giving a steam bath is the bath invented by Messrs. 
Benham and Froud, of Chandos Street, W. C, and called the Portable Oriental 
Vapour Bath. The price is about thirty shillings, and there is apparatus for all 
kinds of fumigation. If a sulphur bath is to be given, the quantity of sulphur 
should be half an ounce ; mercurial remedies may be used also in it. 

c. Different instrument makers keep a variety of simple baths for the administra- 
tion of vapour baths. Hawksley, of Blenheim Street, supplies a capital bath for 
ordinary use at a few shOlings cost. 

2. Simple Water Baths. 

Temperatures. — The following are the temperatures of ordinary baths : — 
Bath. Water. Vapour. Air. 

The cold 40° to 65° F. 

The cool 65° to 75° F. 

The tepid 85° to 94° F 90° to 100° F 96° to 106° F. 

Warm 94° to 98° F 100° to 115° F 106° to 120° F. 

Hot 98° to 112° F 115° to 140° F 120° to 180° F. 



508 BATHS IN SKIN DISEASES. 

The above are the temperatures which I use for the different baths. They differ 
in some slight particulars from those ordinarily given ; for example, a tepid is 
considered to be from 85° to 92° F. > I make the range from 85 J to 94° F. , for patients 
will not care to soak some time in a much lower temperature than 93° or 94° F. 

3. The Turkish Bath. 

In many cases of skin diseases the Turkish Bath does harm, for the reason that 
the blood is determined to the skin, in consequence of the stimulant action of the 
heat upon it. However, there are cases in which the skin, not being hypergemic, 
is sluggish in action as regards the perspiratory function, in which the Turkish 
Bath is of service. The bath is never to be used with the idea of " sweating out " 
impurities through the skin. It gets rid of a certain amount of fluid, and so 
may relieve congestion of internal organs, but then this is not required in skin 
affections. 

4. Wet Packing or Compress. 

This may be employed with advantage in some cases of chronic skin diseases — 
mainly in psoriasis and chronic eczema — to remove scales from diseased surfaces. 
The patient may be wrapped up in a sheet wrung out in cold water, the whole being 
covered over with a blanket, and left for a quarter or half an hour or more according 
to circumstances, in those cases in which more or less of the body is affected by 
scaliness. When the wet-packing process is completed, the parts from whence the 
cuticle comes off must be dressed with some simple cerate or oil. 

5. Oil Packing. 

This may take the place of wet packing in all cases in which the skin is tender 
or much inflamed, and it is especially to be advocated for cases of pityriasis rubra 
or inflamed psoriasis, in which the surface is dry, tender, and more or less inclined 
to crack and excoriate. 

6. Medicinal Baths. 

Medicinal Vapour Baths. — It is needless that I should describe in detail the mode 
of administering medicinal vapour baths. The necessary apparatus can be obtained 
at any instrument maker's. The mineral is volatilized by means of the heat derived 
from a spirit lamp, which is made to play both upon the small tray in which the 
drug is placed, and upon a certain small layer of water, so that steam and medicinal 
vapour may be made to surround the patient's body at the same time. About a 
quarter of an hour or so should suffice for a medicinal vapour bath. If a mercurial 
bath is desired, from fifteen to thirty grains of calomel may be sublimed, and the 
patient on coming out of the bath should not be dried, but put on a clean night 
dress and go to a warmed bed. If a sulphur bath be given, from one to two ounces 
of sulphur may be used. At University College Hospital I have special apparatus 
for these baths. 

Medicinal Liquid Batfis.— These baths are of various kinds. The quantity of 
water in a bath is estimated at thirty gallons. The temperature of the water should 
be from 90° to 95° F., and the amounts of medical substance and the different kinds 
of the latter are indicated in the following table : — 

7. Emollient Baths, made of— (a) Bran, 2 to 6 lbs. ; (&) Potato starch, 1 Tb ; (c) 
Gelatine, 1 to 3 lbs. ; (d) Linseed, 1 lb ; (e) Marshmallow, 4 lbs. ; (/) Size, 2 to 
4 Tbs.— to 20 or 30 gallons of water. Use in all erythematous and itchy and scaly 

8. Alkaline.— {a) Bicarbonate of soda, § ij to §x; (b) Carbonate of potash, § ij 
to 1 vj ; (c) Borax, § iij. The bicarbonate of soda I often use with bran liquor 
made by infusing a gallon of bran. Use in eczema, psoriasis, urticaria, lichen, and 
prurigo, where there is much local irritation. 

9. Acid.— Nitric or muriatic acid, I j ; or a mixture of nitric acid, § j ; or more, 
with hydrochloric acid, in like quantity, to 30 gaUons of water. Useful in chronic 
lichen and prurigo. 

10. Iodine.— Iodine, 3 ss, iodide of potassium, § ss, with § ij of glycerine; or 
iodine, 3 j or more, with I j or 1 ij of liquor potassas, to 30 gallons of water. Use 
in scrofulous eruptions, in syphilis, and in squamous diseases. 



soaps. 509 

11. Bromine. — 20 drops of bromine, with ? ij of iodide of potassium. Use as the 
iodine. 

12. Sulphur et of Potassium. — § ij to § iv to each bath. The balneum sulphuris 
co. of Startin is made with 3 ij of sulphur (precipitated), 3 j of hyposulphite of 
soda, and 3* ss of dilute sulphuric acid, with a pint of water, added to the usual 30 
gallons of water. Use in itch, in chronic eczema, lichen, and psoriasis. 

13. Mercurial. — Bichloride, 3 j — iij, with 3 j of hydrochloric acid. Biniodide 
of mercury, 3 j, with ^ ij of chloride of sodium. Use in pityriasis rubra and the 
syphilodermata, especially with ulceration. The Purton springs in North Wilts are 
bromo-iodated and sulphated waters, having- a temperature of 58-£° F. , and would 
appear to be very useful in strumous subjects. 



CAUSTICS. 

14. Iodine. — Iodine, 3ss; iodide of potassium, 3 j ; distilled water, 3 v. Use in 
glandular enlargements, lupus. 

15. — Nitrate of Silver, 3ij ; spirit of nitric ether, 3 j. (To be kept excluded 
from the light. ) Use in the chronic forms of erythema, eczema, psoriasis, and 
ringworms. 

16. Chloride of Zinc. — Chloride of zinc, 3 iv, chloride of antimony, 3 ij, starch, 
3 j, and glycerine, q. s. Use in ulcerous and tuberculous affections. — Startin. 

17. Arsenical. — Calomel, §ijss; bisulphuret of mercury, 9 ij ; and arsenious acid, 
3 j. — Use in lupus, scrofulous ulcers, and syphilis. — Startin. 

18. Vienna Paste. — Unslaked lime and caustic potash, of each equal parts; 
when used, mix with alcohol. Use as above. 

19. Bicyanide of Mercury. — Gr. ij or more to 1 j of water. Use in acne rosacea ; 
to be painted on for two or three minutes, and then wiped off. — Burgess. 

20. Biniodide of Mercury. — Gr. x to gr. xx to § ss of glycerine. Use in lupus 
especially. 

21. Acid Nitrate of Mercury, 3 ij ; tragacanth powder to make a mass. Use in 
lupus, syphilitic tubercles, nmvus, &c. 

22. Chromic Acid, gr. lx ; water 3 iv. Use for the destruction of warts. 

23. Plencks. — Alcohol and acetic acid, of each § ss ; bichloride of mercury, alum, 
camphor, and carbonate of lead, of each 3 ss. Use in. syphilitic warts; pencil twice 
a day. 

24. Savin (Langston Parker). — Powdered savin, bichloride and nitric oxide of 
mercury, equal parts. Use in condylomata and warts. 

25. Coster's. — Iodine, 3 to 3 ij ; and colourless oil of tar, § j. Use in ringworm 
in the early stages ; six applications suffice. 

26. Nitrate of zinc, 1 part ; bread mass, 2 or 3 parts. Use in lupus, to be spread 
over the surface thinly. 

SOAPS. 

27. Hendrie's Dispensary petroleum soap. Use in eczema. 

28. Juniper-tar- Soap (recommended by Velten of Aix-la-Chapelle). Use in the 
squamous diseases especially. 

29. The common Soft (potash) Soap, used in chronic infiltration — e.g. , lichen cir- 
cumscriptus or chronic eczema. It may be dissolved in boiling water, 3 j of the soap 
to § ij of water, and scented with some aromatic oil. 

30. The Sulphur Soap. Use in scabies and prurigo. 

31. Sapo Laricis (Moore, Dub. IIosp. Gazette, March 15, 1859). — Wheaten bran, 
% iv ; glycerine, § iij ; white curd soap, § xxiv ; extract of larch bark, § vj ; and 
rosewater, § xij. Use in pityriasis, psoriasis, chronic eczema, and herpetic eruptions. 

32. Pears' Transparent Soap.— This is the best soap made, though I have a decided 
objection to the makers' vaunting my name in print in their circular as approving it. 



510 SEDATIVES — LOTIONS AND OINTMENTS. 

33. There are many other kinds of soap, but I am not in the habit of using them 
very much — ex., sulphur, carbolic acid, oxide of zinc, &c, a series of which are 
carefully made by Morstatt and Co. 

ASTRINGENTS. 

34. Alum, gr. xx ; sulphate of zinc, gr. x ; glycerine, 3 j ; rose-water, § iv. Use 
in erythema, intertrigo, eczema. 

35. B. Tannic acid, gr. xl ; French vinegar, 1 ss ; distilled water, § vijss. M. 
Use in seborrhea. — Neligan. 

36. B . Tincture of krameria, 3 ij ; creasote, gtt. viij ; dilute prussic acid, gtt. 
viij ; distilled water, 3 iv. M. Use in chronic eruptions with itching. — Neligan. 

37. B . Opium, gr. viij ; creasote, gtt. x ; lard, g ij I M. Use in prurigo and 
lichen. — Neligan. 

38. B. Tincture of myrrh, gtt. xxx ; oxide of zinc, gr. xx ; cold cream, § j. 
M. Use in prurigo, erytliema, and lichen. — Neligan. 

39. E. Borax, Sjto3j; glycerine,^'; rose-water, g viij. M. Use in squamous 



40. 1£. Oxide of zinc, 3 i j ; glycerine, 3 ij ; lead -water, 3 iss ; lime-water, § yj 
to viij. M. Use in the secretory stage of eczema, in acne, in lichen, foul ulcers, im- 
petigo, and herpes. 

41. B . Dilute hydrochloric or nitric acids. 3 ss to 3 ij ; acetate of lead, gr. v to 
x ; water, § vj. M. Use in eczematous and lichenous affections. 

42. 3. Alum, 3 ij ; infusion of roses, ? xx. H. Use in acne, pityriasis, and 
eczema {sine crusMs). — Cazenave. 

43. B. Sulphate of copper, 3j; sulphate of zinc, § ss ; distilled water, §xvj; 
cherry-laurel water, § ss. M. Use in mcntagra.—Dupey. 

SEDATIVES— LOTIONS AND OINTMENTS. 
Soda. 

44. B . Carbonate of soda, 3 ss ; conium juice, 3 j ; elderflower water, § j. M. 
Use in eczema, lichen, urticaria, to allay itching. 

45. B Bicarbonate of soda, 3 j ; glycerine, 3 iss ; elderflower water, § vjss. 
Use as above. 

45a. B. Biborate of soda, 3 i j ; cherry -laurel water, g j ; elderflower water, 
3 xj. M. Use in lichen. — Neligan. 

46. B. Soda or potash, 3 ij ; water, § vj to 3 viij. M. Use in the early 
stages of vesicular and papular diseases to allay itching. 

Morphia. 

47. B . Borax, § ss ; sulphate of morphia, gr. vj ; rose-water, § viij. M. Use 
in pruritus vtdvce. — Meigs. 

48. B. Solution of hydrochlorate of morphia, 3 iss ; solution of potash, 3 i j ; 
glycerine, § j ; cherry-laurel water, § j ; elderflower water, to 3 xij. Use in pruri- 
ginous eruptions. 

Prussic Acid. 

49. B. Bichloride of mercury, gr. j; prussic acid, dilute, 3j; emulsion of 
almonds, § vj. M. Use in itching, in lichen, in the syphilodermata. 

50. B. Dilute prussic acid, 3 ss to 3j; infusion of marshmallow, gv to J viij. 
M. Use in pruritus. 

51. B • Acetate of ammonia, % ij ; prussic acid, dilute. 3 j ; tincture of digitalis, 
1 iij ; rose-water, % v. M. Use in pruritus, prurigo, lichen, urticaria. — Thomson. 

52. ^ . Acetate of ammonia, § j ; prussic acid, dihite, 3 iss ; infusion of tobacco, 
§ viij. Use, to be sponged on to the part twice a day in pruritus ani seu vulva. 



SEDATIVES — LOTIONS AND OINTMENTS. 511 

53. B . Borax, 3 j ; prussic acid, 3 ij ; rose-water, § viij. Use in the pruritus of 
old people. — Neligan. 

Cyanide of Potassium. 

54. B- Cyanide of potassium, gr. vj ; cochineal, gr. j ; cold cream, 3 j. Use in 
pruritus, urticaria. — Anderson. 

55. B- Cyanide of potassium, gr. v ; sulphur, bicarbonate of potash, of each 3 ss ; 
cochineal, gr. vj ; axungia, § j. Use in eczema with pruritus. — Anderson. 

56. B. Cyanide of potassium, gr. xv; water, § viij. Use in pudendal irritation, 
lichen, and prurigo. N.B. Keep in a dark place. — Hardy. 

Chloroform, 

57. B . Chloroform, Tl\yj ; cucumber cerate, ^ j. M. Use in pruritus. 

58. B • Carbonate of lead, 3 ss ; chloroform, TH_iv ; cold cream, % j. M. Use in 
pruritus. 

59. B- Chloroform, TT^ viij ; glycerine, 3 j ; white wax ointment, 3 vj ; cyanide of 
potassium, gr. iv. Use in pruritus. — Neligan. 

60. B. Acetate of morphia, 1 part; chloroform, 8 parts; lard, 60 parts; oil 
sweet almonds, 40 parts. Use in pruritus pudendi, to be applied two or three times 
a day. — Br. Elleaume. 

61. B- Chloroform, 3j; glycerine, 3 iv. M. — Buparc. 

62. B • Glycerine, 3 ij ; bichloride of mercury, gr. iss ; chloroform, 71\xx ; rose- 
water, 1 vj. M. Use in itching, in papular and vesicular diseases, and urticaria. — 
Burgess. 

Belladonna. 

63. B. Extract of belladonna, § ss ; hydrocyanic acid, dilute, -ss; glycerine, 
§ j ; water, § xiv. M. Use diluted in papular and phlegmonous affections. — 
Startin. 

Bigitalis. 

64. B • Tincture of digitalis, 3 ij to 3 iv ; glycerine, 3 ss ; rose-water, 1 vj. M. 
Use as a lotion in pruritus of purely neurotic character. 

Liquid Pitch. 

65. B- Pitch, 3j; extract of opium, 3j ; lard, |j, M. Use in obstinate prurigo. — 
Buparc. 

Benzoin. 

66. B. Sweet almonds, |j; orange-flower water, 1 i j ; rose-water, 1 viij. Make 
an emulsion, then add muriate of ammonia, 3 j ; tincture of benzoin, 3 ij. M. Use 
chiefly as a cosmetic. — Herman. 

Lead. 

67. Carbonate of lead, gr. iv ; glycerine, 3 j ; simple cerate, § j. M. Use in 
erythema. 

68.^ B- Solution of diacetate of lead, 3j to 3 ij ; infusion of marshmallow, 
§ xvj. M. Use in lichen and chronic eczema. — Burgess. 

Rumex. 

68 A. Rumex ointment, ? j ; hypochloride of sulphur, 3 ij. Use in acne rosacea.— 
Anderson. 

The rumex ointment is made as follows : — Rumex root, 3* xviij ; prepared lard, 
1 xij ; yellow wax, § ij. Bruise the root, boil for two hours in distilled water ; strain 
and evaporate to 3 iv. Add gradually the lard and wax already melted, and stir the 
whole until cold. 

69. B- Solution of acetate of ammonia, § ij ; alcohol, § ss ; rose-water. \ iv. 
M. Use in lichen. — Burgess. 



512 SEDATIVES — LOTIONS AND OINTMENTS. 

Lime. 

70. B . Protcchloride of lime, § ss ; almond oil, § ij ; lard, § iij. M. Use in 
papular itching. — Biett. 

. 71. Glycerine^ § j ; compound tragacanth powder, 3 ij ; honey, 3 ij ; saccharated 
lime solution, § iss ; almond emulsion, | viij. Use, to protect herpes, burns, charmed 
hands, &o. 

Zinc. 

72. 3 . Acetate of zinc, gr. ij ; rose-water, 3 j ; cold cream, § j. M. Use in 
erythema and herpes. 

73. B. Oxide of zinc, 3j; carbonate of lead, 3j; spermaceti, gj; olive oil, 
q. s. To make a soft ointment. Use in seborrhea, where the skin is inflamed. — 

Neumann. 

Camphor. 

74. I5L Camphor, 3ss; alcohol, q. s. ; oxide of zinc, starch, £5|j. M. Use 
as a powder to allay burning heat of eczema. — Anderson. 

75. B. Camphor, gr. viij ; tincture of conium, 3 ij ; simple cerate, 3 j. M. — 

Neligan. 

76. B. Camphor, 3 ss to 33; alcohol, f j; borax, 3ij; rose-water. § viij. M. 
Use in pruritus, eczema, and er\ ' " 



Absorbent Powders. . ^ 

77. 3. Powdered maize, ^iv; oxide of zinc, §j; calamine, 5 ss. M. Absorbent 
poicder for excoriated surfaces. 

78. Powdered maize, § iv ; oxide of zinc, § j ; iris powder, § ss ; oil of almonds, 
gtt. x. Mix. Use as an absorbent powder. 

Aconitine. 

79. B. Aconitine, gr. j to gr. v ; lard, |j. M. 

80. I? . Iodoform, gr. xxx— lx ; lard, I j. Use to dress painful burns, ulcers, 
chancres, and boils. 

81. 3 . Citric acid, 3 ij ; borax, 3 3 ; water, § viij. Use in cancerous ulceration. 

STIMULANT AND ABSORBENT REMEDIES. 

82. B." Soft soap, ?j; boiling water, § xvj ; perfume to taste. M. Use in the 
second stage of eczema to counteract the infiltration. 

83. R. Tar, alcohol, soft soap, aa 1 j. M. Similar to Hebra's Tr. Saponis Viridis 
cum pice. Used in eczema. 

84. B. Alcohol, oil cade, soft soap, aa 1 3 ; oil lavender, 3 iss. M. More elegant 
than the former. — Anderson. 

Kalicreme of Heir a. 

85. B. Soft soap, ^ ij 5 spirits of wine, |j ; dissolve, filter, and add spirits of 
lavender, 3 ij. Mix. Use in seborrhea. ' 

86. 3 • Camphor, gr. x ; glycerine, Tf^x ; fresh lard, § j. M. Startin's camphor 
ointment. Use in erythematous, vesicular, and squamous diseases. 

Borax. 

87. 3. Borax, carbonate of ammonia, aa 3 iss ; glycerine, ^3; hydrocyanic acid, 
dilute, 3 iij ; distilled water, § xvj. M. Use in vesicular and sebaceous diseases, 
diluted from one to four times. — Startin. 

88. 3- Borax, 3ij ; oxide of zinc, 3 j ; solution of subacetate of lead, 3 ij; lime- 
water, § vj to § viij. M. Use in eczema and herpes. 

89. B. Borax, 3 j to 3 ij ; glycerine, 33; lard, 1 j. M. Use in par asitic diseases, 
eczema, erythema, intertrigo, and lichen. 



SEDATIVES — LOTIONS AND OINTMENTS. 513 

90. Borax, 3 j ; alum, 3 j ; glycerine, 1 ij. Use in eczema of the scalp. 

91. Acetate of zinc, gr. iij to gr. v ; lard, § j. Use in lupus.— Weisse. 

Mercurial. 

92. B . Calomel, 3 j ; lard, § j. M. Use in herpes, psoriasis, pruritus vulva. 

93. I£. Protoiodide of mercury, gr. ij to gr. xv ; lard, § j. M. Use in acne. — 
Hardy. 

94. IJ . Bicyanide of mercury, gr. v to gr. x ; lard, § j. M. Syphilitic tubercles. 

95. R • Biniodide of mercury, gr. v to gr. xx ; lard, § j. M. Use cautiously in 
tubercular syphilis, lupus, and acne indurata. 

96. R. Iodo-chloride of mercury, gr. iij to gr. x ; lard, ?• j. M. Use as above. 

97. R • Red precipitate, finely powdered, white precipitate, aa gr. vj ; lard, § j. 
M. Unguentum mercuriale co. Use in sebaceous, squamous, ulcerous, tubercular, 
and papular eruptions. — Startin. 

98. R. Iodide, §ss; glycerine, ^ ij ; olive-oil, § iiiss ; strong mercurial oint- 
ment, |ij. M. The linamentum hydrarg. et iodini of Startin. Use in tubercular 
and cachectic affections. 

99. R. Bichloride of mercury, gr. iv ; dilute nitric acid, 3j; dilute hydrocyanic 
acid, 3 j ; glycerine, 3 ij ; water, § viij. M. Startin's Lotio hydrargyri bichlo- 
ridi. Use in syphilitic eruptions, pityriasis, chloasma, &c. ' 

100. R . Olive oil, 1 i j ; fresh lard, § ij ; red precipitate, 3 j ; oil of bitter almonds, 
gtt. x ; glycerine, 3j. M. Startin's lin. hydrarg. nitrico-oxydi. Use in pityriasis. 

Sulphur. 

101. R. Iodide of sulphur, gr. x to 3 j ; lard, § j. M. Use in acne. 

102. R. Precipitated sulphur, alcohol, aa § j. M. Use in acne. — Hebra. 

103. R. Hypochloride of sulphur, 3 i j ; subcarbonate of potash, gr. x; lard, 
§ j ; oil of bitter almonds, gtt. x. M. Use in acne. — Wilson. 

104. R. Sulphuret of potassium, § ss ; lime-water, § xvj. M. Use in pityriasis, 
pustular ^ and parasitic diseases. 

105. R . Sulphuret of potassium, sulphate of zinc, each 3 3 ; rose-water, § iv. 
Use in acne indurata. — Bulkley. 

106. Sulphur, glycerine, rectified spirits of wine, carbonate of potash, sulphuric 
ether, equal parts. To be rubbed into the part affected with comedo. 

Tar. 

107. R . Tar, alchohol, aa § j. M. Use chiefly in psoriasis. 

10S. R. Pyroligneous oil of juniper, 3 j to § iij ; mutton suet, §ss; lard, 5 j. 
M. Use in eczema and psoriasis palmar is, &c. 

109. R. Tar, 33; camphor, gr. x ; lard, 3 x. M. Use in pruritus, in vesicular 
and. papular diseases.— 2?<zw?#<?. 

Lead. 

110. Tp. Acetate of lead, gr. xv ; dilute hydrocyanic acid, TT|_xx ; alcohol, 1 ss ; 
water, q. s. ad | vj. M. Use in impetigo. 

111. IJ . Iodide of lead, gr. xij ; chloroform, Tltxl; glycerine, 3j; lard, §3. 
M. Use in eczema and psoriasis. — Belcher. 

Silver. 

112. R. Chloride of silver, gr. v to gr. xv; lard, fss; white wax, 3 ij. M. 
Use in psoriasis. 

113. R. Nitrate of silver, gr. ij to gr. x; water, |j. M. Use in eczema and 
erythemata. 

33 



514 sedativp:s — lotions and ointments. 

Bismuth. 

114. B . Subnitrate of bismuth, 3 ij ; bichloride of mercury, gr. x ; spirits of 
camphor, 3 ss ; water, q. s. ad § xvj. M. Lotio bismiithi nitratis. Use in 
sebaceous, pustular, and vesicular diseases, and in pityriasis. Use diluted with from 
1 to 3 parts water. — Startin. 

Phosphorus. 

115. B- Phosphorated ether, 3 j ; cerate, free from water, 3 v. M. Use in 
lupus, syphilitic tubercles, acne rosacea. — Burgess. 

110. B- Phosphorus, gr. ij to gr. v ; ether q. s. to dissolve ; camphor, gr. xx ; 
cerate, § ss. M. Use as above. % 

Zinc. 

117. Py. Oxide of zinc, 3 ij ; calamine powder, 3 ss ; glycerine, 3 ij . rose-water, 
g § viij. M. Use in eczema, generalty where the surface is tender and red. 

118. The same + gr. j of the bichloride of mercury. 

Creasote. 

119. B . Creasote, TT^xxx ; glycerine, 3 iij ; water, § vj to § viij. M. Use in 
pityriasis. 

Various. 

120. I>. Tr. of nux vomica, |sa; spirits of camphor, essence of caraway, aa 
3 ij ; distilled water, § vij. M. Use in chronic lichen simplex. — Neligan. 

Hebra's Ung. Diachyli. 

121. B- Ung. diachyli albi (Plumbi). — This is made by boiling- together olive 
oil, 1 xv, and litharge, 3 iij et 3 vj to a good consistence, and adding 3 ij of oil of 
lavender. Use in eczema, applied twice a day on linen. 

122. IJ . Bichloride of mercury, gr. viij ; distilled water, §iv; sulphate of zinc, 
acetate of lead, aa ±)ij ; alcohol, 3 ij. M. Hardy's lotion for ephelides. Use 
night and morning. 

123. IJ. Mezereon bark, horseradish, aa rj; distilled vinegar, hot, §ij. M. 
Infuse for a week and strain. Use in tinea decalouns. — ■ Wilson. 

124. B. Persulphate of iron, 3j; tincture of iodine, soap liniment, aa § j. M. 
Use in chilblains. 

125. B • Bichloride of mercury, gr. j ; tincture of benzoin, 3 ij ; distilled water, 
§ vj. M. Virgin's milk. Use in acne. 

126. B- Cod liver oil, tincture of cantharides, aa § j. M. Use in syphilitic 
alopecia. — Langston Parker. 

127. B . Cod liver oil, 3 j ; solution of ammonia, 3 ss ; tincture of cantharides, 
§ ss ; honey-water, § ij ; essence of rosemary, § iv. M. Use in syphilitic alopecia. 

— Langston Parker. 

128. B . Balsam of Peru, 3 ij ; oil of lavender, gtt. xij ; simple cerate, § iiss. 
M. Use in loss of hair. 

129. B- Fowler's solution, 33; distilled water, § j. M. Use in lupus. — 
Hooper. 

130. B- Subcarbonate of soda, 3 ij ; extract of opium, gr. x ; slaked lime, § j ; 
lard, 1 ij. M. Use in prurigo. — Biett. 

131. B. Oil of bitter almonds, 3 ij ; cyanide of potassium, gr. xij ; Galen's cerate, 
§ ij. M. Use in itching and prurigo with great caution. 

132. B . Cyanuret of mercury, gr. vj ; simple cerate, § j. M. Use in syphilitic 
ulcers. 

133. B- Chloride of lime, § ss ; oil of sweet almonds, § i j ; lard, 3 iij. M. 
Use in papular itching. 

134. B . Hyposulphite of soda, I j ; glycerine, § j ; water, § iij. M. Use in 
pruritus vaginae. 



MIXTURES. 515 

135. R . Biborate of soda, 3 iss ; hydrocyanic acid, dilute, 3 ss ; glycerine, 3 iij ; 
water, § vj . M. Use in syphilitic palmar psoriasis. — Startin. 

136. R. Ammonio-chloride of mercury, 3j ; olive oil, lard, aa^j ; oil of roses, 
gtt. vj ; tincture tolu, gtt. xx. M. Use in pityriasis capitis. 

137. R . Liq. carbonis detergens, § ss ; glycerine, § ss ; acid hydrocyanic, 
dilute, 7T[xx ; water, § x. M. Use in psoriasis. 

138. R. Citrine ointment, 3 ij ; camphorated oil, glycerine, a5, % ss. M. Use 
in psoriasis. 

139. R . Iodide of lead, gr. xij ; chloroform, gtt. xl ; glycerine, 3 j ; adeps, I j. 
Use in eczema and psoriasis. 

EMPL ASTRA. 

Emplastrum Fuscum of the Continentals. 

140. R . Camphor, 3 ss ; black pitch, 3 vj ; yellow wax, 3 ix ; red oxide of 
lead, § ij ; olive oil, § iv. To be melted together till a little burned. Use 
in boils, 

Emplastrum Hydrargyri {German formula). 

141. R. Mercury, 3iv; turpentine, 3 ij ; yellow wax, 3 iij ; lead plaster, 1 iss. 
Use in acne rosacea. — Neumann. 

MIXTURES. 

Chiefly those of use in more obstinate and chronic cases. 

Mercurial. 

142. B. Bichloride of mercury, gr. -^ toi; dilute hydrochloric acid, gtt. x; 
water, ? j. M. Take at one dose. 

143. R. Bichloride of mercury, gr. j ; iodide of potassium, 3 ij ; water, ^ iij. M. 
Dose : a dessertspoonful three times a day. Use in acne. — Burgess. 

144. R. Bichloride of mercury, ^] ; iodide of potassium, 3 vj ; comp. tincture 
iodine, 3 ij ; water, q. s. ad §xvj. M. Startin's mist, hydrargyri iodidi. N.B. 

3 j contains ^ gr. bichloride and gr. 3 of iodide. 

145. R. Bichloride of mercury, gr. ^ to -fa ; arsenious acid, gr. •£$ to 4V; water 
§ ss. M. For one dose in chronic syphilis. 

146. R . Biniodide of mercury, gr. iij ; iodide of potassium, 3 j to 3 ij ; alcohol, 
3 ij ; syr. ginger, 3 iv ; water, q. s. ad §" iss. M. Dose : 30 drops three times a 

day in secondary syphilis. ^-Puche. 

147. B. Biniodide of mercury, gr. j to gr. ij ; iodide of potassium, §ss; water, 
§ viij. M. Dose : a tablespoonful in a cup of ptisan, with the waters of Bareges 

and Louchon. — Hardy. 

148. R. Donovan's solution, or liq. arsenici et hydrargyri iodidi. Dose : Tf[x 
to xx:; 3 j conta ns gr. £ of arsenious acid, gr. J of peroxide of mercury, and about 
gr. £ of iodine converted into hydriodic acid. 

149. B::omide of mercury j gr. £ ; liquid extract of sarsa, 3 ij , compound decoction 
of s.xrsa, 5 x. For a dose. Use in obstinate secondary syphilis. 

150. R. Bicyanide of mercury, gr. ij ; water, § xvj. M. Dose: one table- 
spoonful night and morning. — Langston Parker. Uses. — The above are used chiefly 
in secondary syphilis ; the 3rd, 5th, 6th, and 8th especially in tubercular forms ; the 
4th and 7th, in ulceration when it is of a syphilitic nature. 

Arsenical. 

151. B. Wine of iron, ^jss; simple syrup, § ss ; Fowlers solution, gtt. xlviij ; 
distilled water, to 3 vj. M. Dose : a tablespoonful twice or thrice a day. § j con- 
tains Tl^iv of arsenical solution. 

152. R. Fowler's solution, Tfjlxxx ; iodide of potassium, gr. xvj ; iodine, gr. iv ■; 
orange-flower water, §ij. M. Dose: a teaspoonful three times a day. Use iu 
eczema. — Neligan, 



516 MIXTURES. 

153. B . Cod-liver oil, § ij ; one yolk of egg- ; Fowler's solution, Tulxiv ; syrup, 3 ij; 
distilled water, q. s. ad § iv. M. Dose: one teaspoonful three times a day. — Wilson. 

154. B . Bromide of iron, 3 ss ; Fowler's solution, 3 j ; elderflower water, § iss ; 
orange-flower syrup, 3 ss. M. Dose : a teaspoonful three times a day. Use in 
ancemic subjects. — Neligan. 

155. B. Arseniate of soda, gr. j to ij ; distilled, 1 viij. M. Dose: one table- 
spoonful daily ; then two, in conjunction with, alternately, alkaline and vapour 
baths, and tincture cantharides night and morning, and the mineral waters of 
St. Sauveur and Loueche. Use — beneficial in lichen, also in psoriasis and chronic 
eczema . — Hardy. 

156. B- Fowler's solution, tincture of cantharides, aa ^ ss. M. Dose: ten drops 
twice a day, increased to fifteen drops. Use in psoriasis especially. — Bennett. 

157. B. Arsenious acid, gr. ij ; distilled water, § j. M. This is an hypodermic 
solution. Three drops may be used once daily, to be followed in four days by the 
injection of three drops twice a day. Five drops may be used after the twelfth 
day. Use in the treatment of chronic skin diseases — ex., psoriasis, lichen, &c. 

158. B- Solution of chloride of arsenic, 3ss; dilute hydrochloric acid, 3 j ; 
tincture sesquichloride of iron, 3 iss to 3 iij ; water, to 3 viij. M. Dose: a sixth 
part three times a day. 

Ferruginous. 

159. B- Sulphate of magnesia, ^ iij ; sulphate of iron, 3 ij; dilute sulphuric acid, 
1 ss; infusion of quassia, q. s. ad 3 xvj. M. Dose : 3 ij to 3 ss. Use in acne, eczema, 

impetigo, and ulcerous affections. (An aperient tonic.) The mistura f erri acid of 
Startin. 

100. B- Sulphate of magnesia, §v; syrup iodide of iron, § j ; oil of peppermint, 
m\x ; water, q. s. ad 3 xvj. M. Dose : 3 ij to 3 ss. The mistura iodidi of Startin. 

161. B . Citrate of iron, 3 j ; iodide of potassium, gr. xviij ; tincture of cantha- 
rides, tincture of cardamoms, aa 3 ij ; water, q. s. ad \ xvj. M. A sixth part 
three times a day. Use in rupia. — Kinnier. 

Various. 

162. B • Sulphate of magnesia, 3 iv : carbonate of magnesia, 3 j ; tincture of 
colchicum, TT^xl ; oil of peppermint, Tf[ j ; water, 3 viij. M. Dose : a sixth part. 

163. B • Bicarbonate of soda, 3 iij ; tincture of calumba, 3 iij ; sal volatile, 
3 iij ; dilute prussic acid, Xviij ; syrup of ginger, 3 iij ; distilled water, to § vj. 

M. A sixth part an hour before two principal meals. Use in dyspepsia. 

164. B- Acetate of potash, 3J; acetic acid, 3 ss ; spirits of nitrous ether, § iss ; 
fluid extract of taraxacum, 3 ij. A teaspoonful before meals with water. Use 
in acne indurata. — Bulk-ley. 

165. B. Iodide of sodium, gr. lx; compound decoction of sarsaparilla, 3 viij. 
Dose : a sixth part three times a day in obstinate syphilitic eruptions where iodide 
of potassium disagrees or fails. 

166. B- Sarsaparilla, § xij ; water, 0. xxiv. Boil for two hours, into which is 
suspended in a linen bag — Alum, 3 iss ; calomel, § ss ; oxysulphuret of antimony, 3 j ; 
liquorice, §" iss ; senna leaves. 3 ij ; aniseed, 3 ss. Remove from the fire and allow 
it to infuse. Strain off sixteen pints. This is decoction No. 1. To make decoction 
No. 2, take the residue of No. 1, with sarsaparilla, 3 vj ; water, O. xxix ; orange 
peel, cinnamon, cardamoms, aa 3 iij ; liquorice, 3 vj. Infuse and strain sixteen 
pints. Use in tertiary syphilis. — Zittman. 

167. B. Turpentine rectified, 3 ss to 3 iss; creasote, TT^viij ; spirits of rosemary, 
TT^xl; water, q. s. ad § iv. M. Dose: two teaspoonfuls every three hours. Use 
in purpura. — Build. 

167a. B • Tincture of guaiacum, § j ; tincture of aconite, Tfl xx ; camphor mix- 
ture, 3 vj. M. Dose : % ss three times a day in chronic skin diseases. 

168. B. Borax, 3j; bitartrate of potassa, § ss ; white sugar, 3 ij ; water, § xvj. 
M. Dose : two tablespoonfuls every six hours. Use in erythema nodosum. — 
Neligan. 



PILLS, ETC. 



517 



169. B. Almond oil, tss; olive oil, % ij ; iodiDe, gr. \. M. Dose: a third 
part three times a day. Use in scrofulous eruptions. — Duncan. 

170. ^. Compound tincture of guaiacum, 3j; tincture of serpentaria, 3 ss; 
mucilage, TT^xx; decoction of mezereon, 3viiss; decoction of dulcamara, 3j. 
M. To be taken three times a day for psoriasis guttata.— Nelig an. 

Phosphorus. 

171. B. Phosphorus, gr. x; almond oil, §j. M. Dose: five or ten drops in 
emulsion. 

172. B. Phosphorus, 4 parts; ether, 100 parts. M. Dose: five to ten drops. 
Use in acne especially. 

Strychnine. 

173. B . Strychnine, gr. -£ — 1 ; dilute phosphoric acid, 3 iij ; tincture of orange 
peel, \ ss ; infusion of cloves, § xj. M. Dose : half an ounce three times a day. 
. Use in prurigo and lichen. 

174. B. Dilute nitric acid, 3 ss ; dilute phosphoric aci'd, 3j; solution of 
strychnine, TTLxviij ; tincture of orange peel, 3 iv ; syrup of ginger, 3 iv ; water 
to | vj. A sixth part twice a day. Use in debility. 

PILLS, ETC. 

Mercurial. 

175. I? . Iodo-chloride of mercury, gr. iv ; gum Arabic, gr. xv ; bread crumb, 
3 iiss ; orange-flower water, q. s. Make 100 pills. Dose : one to three daily. 

Use in acne. — Bochard. 

176. B. Biniodide of mercury, gr. j to ij ; extract gentian, 3ij. Make 12 pills. 
One pill twice a day. 

177. B . Protoiodide of mercury, gr. xvj ; extract of lettuce, 3 ss. Make 40 
pills. Dose : one to four daily. Use in syphilodermata. 

178. B . Bicyanide of mercury, gr. xxiv ; muriate of ammonia, 3 iij ; guaiacum, 
§ iij ; extract of aconite, 3 iij ; oil of anise, gr. xxiv. Make 400 pills. Dose : one 

pill three times a day. Each pill contains -^ gr. of the bicyanide. Use in syphilis. 
— Langston Parker. 

179. B • Bicyanide of mercury, gr. j ; quinine, gr. xx ; extract of gentian, gr. 
xxx. To make 20. One twice a day. Use in ordinary syphilitic eruptions. 

Arsenical. 

180. B . Arseniate of soda, gr. ij ; water, sufficient to dissolve ; guaiacum 
powder, 3 ss ; oxysulphuret of mercury, 3j. Mucilage sufficient to make 24 pills. 
Dose : one two or three times a day. Use in chronic skin diseases. — Wilson. 

181. B. Arseniate of soda, gr. ij ; extract of hops, gr. xx; sulphate of iron, 
gr. xx ; extract of nux vomica, gr. iij. M. Make 24 pills. One three times a 
day. Use in chronic eczema and psoriasis. 

182. B. Levigated arsenious acid, gr. v; powdered acacia, 3ss; cinnamon 
powder, 3 iij ; glycerine, enough to make 100 pills. Pil. Arsenicalis composita. 
Dose : one or two a day. Each pill contains 2 L o g r - arsenious acid. 

183. B . Arsenite of iron, gr. iij ; extract of hops, 3 j ; powdered marshmallow, 
3 ss. Orange-flower water enough to make 48 pills. Dose : one to two daily. 

Use in chronic psoriasis and lupus. — Biett. 

184. B. Iodide of arsenic, gr. ij ; manna, gr. xl ; mucilage, q. s. Make 20 pills. 
Dose : one pill three times a day. Use in psoriasis. 

Variw. 

185. B. Extract of aconite, extract of dandelion, Sa gr. xv. Make 40 pills. 
Dose : two pills night and morning. Use in prurigo, in conjunction with starch 
baths and arseniate of iron. — Cazenave. 



518 REMEDIES FOR PARASITIC DISEASES. 

186. R. Extract of nux vomica, gr. iij ; inspissated ox-gall, gr. vj ; extract of 
dandelion, gr. xxiv ; myrrh, gr. xxiv. Make 24 pills. Dose : one pill three times 
a day. Use in. prurigo. — Neligan. 

187. R . Phosphorus, gr. iij to gr. xx ; almond oil, gtt. x to lx ; powdered acacia, 
q. s. Make 12 pills. Dose: one twice a day. U se in lupus and syphilitic tubercular 
disease. — Burgess. 

188. R. Sublimed sulphur, § ij ; bitartrate of potassa, §3; powdered rhubarb, 
3 ij ; powdered guaiacum, 3 j ; honey, tt)j. M. Dose : two tablespoonfuls three 

times a day. Use in chronic skin disease. 



REMEDIES FOR PARASITIC DISEASES. 

Those agents which are destructive to parasites are termed Parasiticides. 

Remedies for Scabies and Prurigo. 

189. R . Sulphuret of potassium, 1 vj ; white soap, Ibij ; olive oil, Oij ; oil of 
thyme, 3 ij. M. Use in scabies and prurigo. — Author. 

200. R. Olive oil, 3 ij ; sulphate of potash, 3 xv ; sulphate of soda, 3 xv ; pre- 
cipitated sulphur, 3 x. M. Use in scabies. — Mollard. 

201. R. Sulphur, tar, aa 3 vj ; soft soap, lard, aa, 3 xvj ; chalk, 3 iv. M. Use 
in scabies. — Hebra. 

202. R . Lard, I ij ; sulphur, 3 v ; carbonate of potash, water, aa 3 ij. M. 
Use in scabies. — Hardy. 

203. R • Ammonio- chloride of mercuiy ointment, 3 j ; musk, gr. ij ; oil of laven- 
der, gtt. ij ; almond oil, 3 j. M. Use in prui igo and scabies. — Wilson. 

204. R • Iodide of sulphur, iodide of potassium, aa 3 iss ; water, 3 xxxii. M. 
Use in scabies. — Cazenave. 

205. R. Olive oil, § ss ; lard, 3SS; powdered stavesacre, 3 ij. M. Use in 
phtheiriasis. 

206. fy. Chamomile powder, lard, olive oil, ai 3 j. M. Use in scabies. Said 
to cure in three frictions. — Bazin. 

207. R. Sublimed sulphur, 3 ss ; ammonio-chloride of mercury, gr. v ; sulphuret 
of mercury with sulphur, gr. x. Mix, and add olive oil, 3 ij ; creasote, gtt. iv ; 
fresh -lard, 3ij. M. JJse in scabies. Ung. sulphuris co. of Star tin. 

208. R . Olive oil, 3 ss ; adeps, 3 ss ; powdered stavesacre, 3 ij. Mix. Use in 
phtheiriasis. 

YleminglJs Solution. 

209. R. Quicklime, Ibj ; flowers of sulphur, Ibij; water, Ibxx. Boil until 121b 
remain, and then filter. Use in scabies. 

210. Iodide of potassium ointment is very efficacious in scabies. 

211. R . Sulphur ointment, 3 ij ; oil of chamomile, gtt. xx. M. Use in scabies. 

212. For phtheiriasis the ordinary white precipitate ointment of the Pharmacopoeia 
is as good as any. 

213. R. Liquid storax, § j ; adeps, § ij. Melt and strain. Use in scabies. — 
Anderson. 

REMEDIES FOR VEGETABLE PARASITIC DISEASES. 

1. Vesicating Parasiticides {to be applied, wlien it is desired, at the outset, to destroy 
the fungus in an early stage of disease). 

214. R. Bichloride of mercury, 3ij ; dilute hydrochloric acid, 3 ss ; alcohol, 
" iv. M. Use in early stages of tinea tonsurans. KB. This formula is not mine. 

215. R. Bichloride of mercury, gr. x. to xx ; elderflower ointment, § j. M. 
Use in early stages of favus and tinea tonsurans. 



REMEDIES FOE PARASITIC DISEASES. 519 

216. B- Compound tincture of iodine, |j; iodine, gr. x; iodide of potassium, 
gr. xv. M. Use in chronic stages of parasitic disease. See also No. 25. 

217. B- Carbolic acid, 3 j ; glycerine, 3 ss to 33. M. Use in tinea tonsurans. 

218. I). Powdered cantharicles, § ij ; concentrated pyro-acetic acid, 3 viij ; tannic 
acid, ? j. M. Macerate for a week and strain. Use in tinea decaUans. — Martin. 

2. Milder Parasiticides {for ordinary use). 

219. B • Sulphuret of potassium, 3 iij ; soft soap, § j ; lime-water, § viij ; alcohol, 
I ij. M. Use in scabies and ringicorm. — Green. 

220. B . Hyposulphite of soda, § iij ; dilute sulphurous acid, § ss ; water, q. s. 
ad § xvj. M. Use in all forms of 'parasitic disease. — Startin. 

221. B- Bichloride of mercury, gr. ij to iv ; alcohol, 3 iv; muriate of ammonia, 
3 ss ; rose-water, q. s. ad § vj. M. Use in scabies, phtheiriasis, and tinea versicolor. 

222. B. Precipitated sulphur, 3 ij ; spirits of camphor, 3ss; glycerine, § ss ; 
bisulphuret of mercury, 3ss; powdered starch, 3 ij j water, ad § xvj. M. Use in 
tinea tonsurans. — Startin. 

223. B. Carbolic acid, 3 ij ; glycerine, § j ; rose-water, q. s. ad 1 viij. M. Use 
especially in tinea circinata. 

#24. B- Borax, 3 ij ; glycerine, 3j; lard, §j. M. Use in tinea circinata. 

225. B- Yellow sulphuret of mercury, 3ss; oil of almonds, glycerine, aa 3 ij ; 
lard, 3 ij. M. Use in tinea. — Bazin. 

226. B . Pyroligneous oil of juniper, 3 ij to 3 iv ; lard, § ijss. M. Use in tinea. 

227. B . Hyposulphite of soda, 3 iv ; glycerine, § j ; distilled water, to % vj. Use 
in tinea versicolor and in pruritus vulval. 

228. B . Soft soap, 3 ij ; pyroligneous oil of juniper, alcohol, glycerine, aa 3 ss. 
M. Use in tinea. — Begbie. 

229. B- Biborate of soda, 3iv; glycerine, 3 ij ; water, q. s. ad § vj. M. 
Use in tinea versicolor. 

230. B • Citrine ointment, 3 iv ; sulphur, 3 ij ; creasote, gtt. x ; lard, 3 j to § ij. 
M. Use in ordinary ringworm and tinea sycosis. 

231. B- White precipitate, gr. vj ; red precipitate, powdered, gr. vj ; lard, § j. 
M. Use in all forms of ringworm. — Startin. 

232. B- Sulphur, tar ointment, aa § j ; glycerine, 3 iv. M. Use same. 

233. B • Carbonate of copper, 3 ij ; lard, 3 j. M. Use generally in parasitic 
diseases, especially in tinea sycosis. — Devergie. 



Depilatories. 

234. B- Fresh lime, 3 ij ; sal sodas, 3 ii j ; simple cerate, 3 ij. — Bayer. 

235. B • Sulphuret of arsenic, 3 j ; fresh lime, 3 ij ; starch powder, 3 iij. M. To 
be made into a paste with water, and allowed to remain on the skin for five minutes, 
or until a sensation of heat is produced. 

236. B- Sulphuret of soda, 3 parts; starch, 10 parts ; lime, 10 parts. 

237. P>. Lime, ^ iss ; sulphuret of arsenic, 3 j ; starch, 3 x. 

SootMng Applications. 

238. B« Oxide of zinc ointment benzoated, ^ ij ; glycerine, 3 iij ; spirits of rose- 
mary, gtt. xv. 

239. B« Laudanum, Goulard's extract of lead, aa | ij to 3 iij ; elder ointment, § ij. 

Special Stimulants of tlie Scalp. 

240. B- Glycerine, 3 iij ; lime-water liniment, § iv; tincture cantharides, 3 iij. M. 



520 REMEDIES FOE PARASITIC DISEASES. 

241. 5 . Distilled vinegar, § iiiss ; tincture cantharides, 3 vj to 3 viij ; rose-water, 
1 iiiss. M. 

242. ly. Strong ammonia liniment, § ss ; castor oil, § ss ; spirits of turpentine 
purified, §ss; white precipitate, gr. xv. M. Brush into the scalp with a hard 
nail-brush until irritation is set up. 

243. 1$. Tincture of cantharides, §j; distilled vinegar, 1 iss ; glycerine, 3 iss ; 
spirits of rosemary, § iss ; rose-water, to 3 viij. M. To be well sponged on to the 
scalp night and morning. 



GLOSSAEIAL INDEX. 



Accidentals in skin diseases, 4. 

Achor (axo>p scurf) is a term at one time applied to a small acuminated pustule of the 
scalp, containing straw-colored pus, and succeeded by a thin brown or yellowish 
scab. The word has now fallen quite into disuse, 37. 

Achorion. The generic name given to the vegetable parasite in tinea favosa. It is prob- 
ably a form of penicillium glaucum, 430. 

Acarus. A genus of minute insects belonging to the acarides in the division of arachnides. 
The following two varieties are found on man : — (1) acarus autumnalis — the harvest- 
bug — (2) acarus scabiei, or itch insect, p. 419. The so-called' acarus Stockholmii is 
probably a species of tick, and the acarus folliculorum is now termed steatozoon folii- 
culorum, 490. 

Acarus scabiei (difference of sex), 419; habits of, 417 ; selective seat of, 418 ; male, 419 ; 
female, 420. 

Acne should really be acme, from the Greek dic^t). Dr. Greenhill believes that in the 
word " acne " the n is by mistake placed for m, and that this error arose with Aetius. 
By acne is meant an inflammation of the sebaceous follicles due to retention of 
sebaceous matter, and this was tiiought to occur at the acme of the system, 4@o. 

Acne, general description of, &c, 4^ ; syphilitic, 289 ; from tar, 133. / 

Acrochordon (ax-po? extreme, and x°P&n a string). A wart which has a pedicle or a thin 
neck by which it hangs from the skin : a pedunculated wart, 334. 

Acrodynia (axpov the extremity, and 6Svvrj pain). The name given by Alibert to an 
epidemic erythema as occurring in Paris some years since, in which there were severe 
pains of rheumatic character about the wrists and ankles. 

Acute Specific Diseases (eruptions of), SO. 

Addison's keloid, 339. 

Age (influence of), 8. 

Ainhum, 362. 

Agrius, an adjective signifying inflamed, derived from ayp\o$ angry, fierce, &c. See 
Lichen Agrius, 139. 

Aleppo evil, 245. 

Alibert's keloid, 347. 

Alopecia signifies baldness— derived from dXuvriZ a fox, in whom the hair falls out in 
mangy places, 500. 

Alopecia areata, 501. 
" syphilitic, 294. 

Allosteatodes [a\\og other, crreap fat), altered sebaceous secretion, 488. 

Alphos (aA;/)6? white), a term applied to lepra vulgaris because of its abundant white 
scales, 259. 

Anaesthesia, 390. 

Anaesthetic leprosy, 313. 

Anatomy of the skin, 14. 

Angeiectasis (dyyzToy a vessel, eK-mo-i? extension), a term applied to hypertrophy of the 
vessels of the skin, or naevoid growths, 364. 

Angeioleucitis (ayyeTov a vessel, \cvkos white, itis signifying inflammation), inflamma- 
tion of the lymphatics. 

Anidrosis (a not, idpuaris perspiration), deficiency or even absence of perspiration, 480. 

Anomalous exanthem, a term applied to those rosy rashes which are like measles and 
scarlatina. False measles, rubella, 93. 



522 GLOSS AEIAL INDEX. 

Anthrax (avQpag a burning coal), a term applied to carbuncle, from its dark coal-like ap- 
pearance. It is also thought that the word carbuncle was used to designate the 
disease from the supposed resemblance of the inflammatory swelling to the stone 
carbuncle, 232. 

Area, a bald spot (from areo, to be dried Tip). It has the same significance as alopecia. 
The ordinary bald spots on the head are called alopecia areata, 501. 

Army itch, 423. 

Arsenical remedies, see Formula, Nfos. 515 et seq. 
11 caustic, see Formula, No. 17. 
" rashes, loo. 

Asteatodes (a not, areap fat), deficient secretion of sebaceous matter, 4S7. 

Atrophic diseases, 330. 

Atrophia (a not, rpotyn nourishment), defiicient nourishment, atrophy. 

Aurungzebe, synonym of Delhi boil, called after the emperor of that name, who had the 
disease, 241. 

BACCHIA, a synonym of acne rosacea (from Bacchus, the god of wine) ; it being supposed 

that the too free use of spirits was the cause of the disease, 4'J4. 
Bakers' itch, 139. 
Baldness, 501. 

Baras, an Arabian designation for leprosy. 
Barbadoes leg (bucnemia tropica, or elephantiasis Arabnm), hypertrophy of the fibrous 

tissues of the legs, commences with inflammation of the lymphatics, 358. 
Baths, nee Formulary, Nos. 1 to 13. 
Beaupui they treatment of leprosy, 328. 
Belladonna rash, 135. 
Berat, one of the ancient terms used to designate the true leprosy; it signifies "bright 

spot." Berat lebena was the bright white leprosy, or the leuce of the Greeks, and 

berat cecha the dark leprosy, or the rnelas of the Greeks. 
Bhau Daji treatment of leprosy, 328. 
Bi.>kra bouton, 240. 
Blebs, 32. 

Bloody sweating, 482. 

Boak, the Hebrew term for the lepro vulgaris, or alphos of Celsus. 
Boils, 231. 
Bots, 400. 

Bouton d'Alep, 245. 
Bricklayers' itch, 139. 

Bromidrosis (jSpo>/u°s a stench, Jfyws sweat), fetid perspiration, 480. 
Bromides, ervptions from, 134. 
Bucnemia (0ov, a Greek augmentative, Kvfipri the leg), the same as Barbadoes leg. 

Literally, bulky or tumid leg, 358. 
Bucnemia tropica, 358. 
Bug, 406. 
Bug bites, 406. 
Bulla, from the latin bulla, a bubble. It is the term applied to blisters or large vesicles, 

as seen in herpes and pemphigus, 32. 
Bullous diseases, 199. 

kt li of syphilitic nature, 287. 

CACOTROrniA (<cavi/ bad, and rpoQit food), ill-nourishment. 

Callosities (Callosics, thick-skinned), 333. 

Calvities, from cafams bald, a term generally signifying the baldness of old age. 

Cancer, Latin for a crab, 382. 

Cancroid, cancer, and clSos likeness, is the term applied to diseases like cancer, or semi- 
malignant affections like kelis. 

Canities (canus hoary), whiteness of the hair. 

Catarrhal inflammation, see Eczema. 

Carate (from the Portuguese cards, complexion), a pigment disease (dsficiency) seen in 
I\ew Granada, 403. 

Carbuncle, differently derived by authors, from carbo charcoal, because of the black 
slough or carbuncle, because of the red and fiery nature of the disease itself, 232. 

Carcinoma (xapidvbifia=>KapKivo<:, cancer), 382. 

Causes, general summary of, 49. 

Caustics, see Formulae, Nos. 14 to 26. 



GLOSS AKIAL INDEX. 523 

Chalazion (xa~Saga. hail or sleet). It is the term sometimes applied to the little sebaceous 

cvsts found in the eyelids, which look like hail-stones. 
Charbon, 288. 
Cheloid (xrin a crab's claw, and eldog likeness), the disease usually called keloid, which 

consists of an indurated mass putting forth processes at its edge that resemble a crab's 

claw. See Keloid. 
Chigoe, 406. 

Chionyphe Carteri, 470. 
Chloasma (xAoag'w to be pale green), generally applied to the brownish stain of pityriasis 

(or tinea) versicolor, one of the ringworms, but used by Hebra to signify pigmentary 

discoloration, 462. 
Chromatogenous (xpcD/^a, xpuparog colour, yevvaca to produce), a term applied to the group 

of diseases in which the colour of the skin is changed, 399. 
Chromidrosis (xjaw^a and Uyoais sweating), coloured sweating, 481. 
Cicatrices, 47. 

Cimex lectularius, or bed bug, 406. 

Cingulum, the Latin for a girdle, and applied to herpes zoster or shingles. 
Classification, 56. 

Willan's, 56. 
Clavus (a nail), a term signifying a corn or callosity, 333. 
Climate, different disease in different, 9. 
Cnidosis (kvi&cjvis an itching, caused by the nettle or KviSn), the term used by Alibert to 

designate the nettle-rash. 
Cochin China ulcer, 249. 
Colour, alterations of, in disease, 399. 
Comedones (comedo a glutton), the small sebaceous plugs or concretions that form in acne ; 

they are also called grubs, 490. 
Condylomata, 334. 
Contagious impetigo, 224. 
Corium (xopiov any skin or leather), structure, 17. 

" remarks on diseases of, 25. 

" diseases of, 339. 
Copaiba eruptions, 135. 
Corns, 883. 
Couperose, the French for copperas. Ooutte rose, signifying acne, in which the colour is 

reddish. 
Cow-pox, a synonym of vaccinia. 
Crusts, 44. 

Crusta lactea, literally milk crust. This is a term that is generally applied to an im- 
petiginous eczema in children, in which the crusting is free and light-coloured ; but 

it has been made to include many different affections, and has no definite signification. 

See Eczema. 
Cutaneous haemorrhages, 392. 
Cutaneous neurosis, 395. 
Cyanoderma (kv6.veos blue, Sippa skin), a blue discoloration of the skin, 403. See 

Chromidrosis. 
C> r anopathia (kv6veos blue, -rraOog disease), the blue disease, or cyanosis. 
Cysts of perspiratory glands, 485. 
" sebaceous glands, 491. 

Dactylitis syphilitica (6&xtv\o$ a finger), a tertiary disease, 297. 

Dandriff. or Dandruff, signifies scurfiness, pityriasis of the scalp, 331 . 

Dartre (Sapr6s, flayed), a term applied by the French to the group of diseases including 
eczema, lepra vulgaris, lichen, and pityriasis. These are supposed to depend upon a 
'' dartrous diathesis." The word dartre is equivalent to tetter. 

Delhi Boil, an endemic disease of India, 211. 

Demodex folliculorum (So^ds fat, Sixvu, Snlopal, to bite (Hoblyn). The term given by 
Owen to the insect found in the sebaceous matter ; called by Wilson steatozoon folli- 
culorum, 490. 

Dengue, or dandy fever, 101. 

Depilatory (de from, pilus a hair), a remedy which causes the hair to fall off; it is 
iisuaUy made up of quicklime, subcarbonate of potash, and sulphuret of antimony. 
See Formula, ^os. 234 to 237. 

Dermatitis QSippa skin and itis signifying inflammation), inflammation of the skin. 



524: GLOSSARIAL INDEX. 

Dermatalgia (6ipy.a skin, and a~Xyo<; pain), neuralgia of the skin. 

Dermatolysis {6ipp.a skin, and Xvaig looseness), of the skin when it hangs in folds, 358. 

Dermatology (SZpua skin, and \6yos a- discourse) ; that branch of science which relates to 

the physiology and patholog}- of the skin. 
Dermatophyton (dfpua skin, cpvrdv a plant, a vegetable parasite). The diseases in which 

fungi occur are called dermatophytic, 425. 
Dermatophytic diseases, 425. 
Dermatospasmus, means spasms of the skin. 
Dermatopathia, diseases of the skin in general. 

Dermatosis is used in the same way to designate diseases of the skin as a whole. 
Dermatozoa (6ipna skin, g&ov an animal), animal parasites, 405. 
Dermic means relating to the skin ; Dermoid, skin-like. 
Diagnosis (Sidyvwais, a distinguishing), the art of distinguishing diseases. 
Diagnosis of skin diseases (general) 59. 

" age of patient, 62. 

" course and general features, 59. 

" duration of disease, 61. 

" indications from mode of onset, 59. 

" occupation of attacked, 62. 

11 periodicity, 61. 

14 recurrence, 62. 

" seat of disease, 63. • 

" temperament of patient, 61. 
Diagnostic features of eruptions, 63. 

" of syphilitic eruptions, 304. 

Diathesis (SiaOeais a placing in order, a disposition), the general term for certain 

constitutional tendencies, such as the rheumatic, scrofulous, hemorrhagic. 
Diathesis, gouty, 11, 71. 

" influence in skin diseases, 11. 

" strumous, 11, 72. 

" syphilitic, 11, 73. 

" tuberculous, 72. 
Diathetic diseases, 275. 

Discolorations, or maculre, varieties of, 399. 

Dracunculus (deriv. of draco, a dragon), the Guinea-worm, 407. 
Dyers, diseases in, 51. 
Dyes, diseases from, 108. 

Dyschroma (Svoxpoca), discoloration of the skin. 

Dyscrasis (dvaKpaaia bad state of body), a faulty state of the fluids of the blood. 
Dysidrosis (8vg signifying difficult, 'ISpwcris sweating), 476. 

Ecchtmosts (^v^/twat?), extravasation of blood. 

Ecphyma (£*</> u/i a), a pimply eruption. Mason Good applied the term to corns, warts, and 

the lik<\ 
Ecthyma (JkQvjxcl a pustule), a variety of pustular disease, 227. 

" syphilitic, 2S9. 
Ectrotic (lktpgjtikos abortive), a term applied to remedies that arrest the development 

of disease. 
Eczema (JxgEna, from Ugeiv to boil over), a variety of cutaneous diseases of vesicular 

nature, 162. 
Eczema, definition of, 163. 

'" diagnosis, 182. 

" etiology, 174. 

" infantile, 167. 

" local varieties of, 167. 

" marginatum, 170, 450. 

" treatment, 185. 

" varieties of, 163. 
Elementary lesions, the types of form assumed by skin diseases, 27. 
Elephantiasis (fosQas an elephant). This designation is applied to two different diseases 

in which the skin is swollen and indurated like an elephant's skin. The one is 

elephantiasis Grsecorum or true leprosy (310), the other elephantiasis Arabum 

(Barbadoes leg), or more generally now known as bucnemia tropica, or spargosis, 358. 
Elephant leg, 358. 



glo3saei.il lsdex. 525 

Ephelis (Itt\ upon ij\ios, the sun), sunburn or freckles, 403. 

Ephidrosis ( i<piSpoj<7i<;, slight perspiration), moderate sweating. 

Epidermis (i-iSsp/xis the cuticle), structure of, 15. 

Epidermophyton (iTuSepuis epidermis, <pvrdv a plant), a fungus attacking the epidermic 

cells. 
Epinyctis {l-\ upon, vi\ the night), a pustule painful at night. The term was applied by 

Sauvages to ecthyma. 
Epiphyta (eti upon, <pv-dv a plant, epiphytes), fungi found on the surface, 429. 
Epithelioma, epithelial cancer, 382. 
Epizoa (c-i upon, guov an animal), animal parasites riving upon the surface, such as acari, 

lice, etc., 405. 
Equinia (equus the horse), the equine disease, 94. 
Erysipelas (eputfpb? red, TreAAa skin), a peculiar kind of skin inflammation dependent on a 

special poison, 88. 
Erythema (epvdrfixa redness), simple redness of the skin, 2S. 

" as. a separate disease, 107. 

Erythemata, diagnostic features of, 63. 
Erythematous diseases, 107. 
Eruption, multiformity of, 8. 

" _ uniformity of, 8. 
Essentials of skin diseases, 4. 
Esthiomenon (from i<r9ia> to eat), eating; an ulcerating or eating out sore; generally 

applied to lupus in olden time. 
Etiology of skin diseases, 49. 
Exanthem (etjave-q/xa a breaking out). A term applied to febrile diseases which are 

accompanied by erythematous eruptions. 
Excoriations, 47. 

Excreta, influence of retained, 70. 

Exormia (egop/A7? a going or breaking out). This is an old appellation of ecthyma, prob- 
ably. 

Farcy (from farcio to stuff). The disease is a variety of equinia or glanders, 94. 

Favus (a honeycomb), one of the parasitic diseases in which the fungus grows up into 

mass like honej-comb; it is properlv called tinea favosa, 429. 
Ferruginous mixtures, see Fohmulje, Xos. 159 to 161. 
Fibroma (flbra a fibre), the disease in which tubercles formed by hypertrophy of the white 

fibrous tissue of the skin occurs. This is often called fibroma molluscum, 351. 
Filaria medinensis, the guinea-worm, 407. 
Fish-skin disease — i. e., icthyosis, 335. 
Frambaesia or yaws, a disease seen in hot climates, in which tubercles like raspberries 

appear ; hence the derivation, framboise a raspberry, 95. 
Flannel, its action as an irritant, 52. 
Flea bites, 405. 
Follicular hvperaemia, 127. 
Freckles, 402. 

Fungi, parasitic, detection of structure, &c. , 426, 427. 
" of favus, 430. 
" tinea tonsurans, 433. 
" tinea circinata, 455. 

" tinea sycosis, 458. 
" tinea versicolor (chloasma), 463. 
" decalvans, 460. 
Fungus foot of India, Madura foot or podelkoma, or ulcus grave. A disease of the foot 

and hand, due to the presence and development of a fungus allied to a mucour, and 

named Chionyphe Carteri, 468. 
Functional disturbance of internal organs, 10. 
Furf uraceous {fromfarfur, bran), branny, scaliness. 
Farunculus (a boil), supposed to be derived from fur, a thief, 231. 
Furuncular affections, 230. 

Gale, the French for itch. 
Gelatio (from gelare, to freeze), frostbite. 
Glands, anatomy of, sebaceous, 21. 
" sweat, 22. 



526 GLOSS ARIAL INDEX. 

Glands, diseases of — 
"• sebaceous, 486. 
" perspiratory, 475. 

Glanders, 94. 

Gnats, eruptions caused by, 425. 

Gouty diathesis, 11. 

Gout, influences of, 71. 

Gown-red, toothrash or strophulus. 

Grando (a hailstone). Alee Chalazion, a small sebaceous cyst of the eyelid, like a hail- 
stone. 

Grocer's itch, 139. 

Grutum, the term signifying grit, and meant to express the millet-seed or grit- like ap- 
pearance of enlargements of the sebaceous glands of the face. 

Guinea-worm disease, 407. 

Gum-red, a synonym of strophulus. 

Gutta rosacea, literally a rosy drop ; in French, goutte rose ; La.^n, gzttia, a drop ; a term 
applied to acne rosacea, 483. 

ILematodyscrast v (al/xa, aluaros, blood ; Suo-xpacna bad temperament), an unwholesome 

condition of blood. 
Hasmatoma (ai/uai-ou> to make bloody), a sanguineous cyst. 
Hsemidrosis {al/xa blood, 'iSpuxn? sweating), blood perspiration. 
Hair follicle, structure of, 19. 
Hair, diseases of, 40'3. 
Handicrafts as causes of disease, 52. 
Harvest-bug, the acarus autumnalis. 
Henle's layer, 21. 
Hereditary syphilis, 277. 
Herpes (epTTw or e>7i €ti/ to creep), originally signifying a creeping or spreading eruption, 

and applied to ulcerating diseases such as lupus. Now it is limited to an eruption of 

vesicles seated upon a red base, 200. 
Herpes and its varieties, <i-c, 200 — 219. 

" iris, 203, and also 21 S et scq. 

" syphilitic, 285. 
Herpetic' diathesis, 200. 
Herpetism, 200. 
Heterologous (eTepos other, and Adyos an account), a term applied to new formations, 

differing in character from tissues which already exist normally in the body, such as 

cancer, tubercle. 
Heteroplasia (TrAao-i? formation). It has the same signification as the last word— literally 

abnormal structure. 
Hidroa and Hidrosis (i5pi>? sweat, i'Spwo-is sweating) ; the first is a term for miliaria, but 

is used differently by Bazhi. 815 ; the second for excessive sweating, 475. 
Hives, the popular name for chicken-pox. 
Hordeolum (a diminutive of hordeum barley), a sty or inflamed Meibomian gland in the 

eyelid, so named from its resemblance to a barley-corn, 231. 
Horn-pock, the modified form of small-pox, in which the vari abort and dry up into 

hardish papulations. 
Horns, 333. 
Hospital' practice, 9. 
Huxley's layer, 21. 
Hydrargyria (uSpapyvpo? mercury), the erythema produced by mercury applied locally; it 

is sometimes called eczema mercuriale. 
Hvdroa (iiSoo.o water) is the same as hidroa, 215. 
Hydro- adenitis (vSujp and adenitis, gland inflammation), inflammation of the sweat 

glands, 485. 
Hyperemia (u-=p, over or above, and al/ixo, blood), excess of blood ; congestion of an 

active kind. 
Hvperaesthesia (virip over, and alo-^tn?, sensation), exalted sensibility of apart, 396. 
Hyperidrosis (uirep in excess, and 'iSp^a-is, sweating), excessive sweating, 475. 
Hyperplasia (un-ep above, and n-Aacns, conformation), excessive formation of tissue. 
Hypertrophy (un-ep and rpo^, nutrition), an excess over and above the standard nourish- 
ment of a part, by which change of size and form are brought about — in a word, ex- 
cessive growth. 



GLOSSAEIAL INDEX. 527 

Hypertrophia venarum, 363. 
Hypertrophic and atrophic affections, 330. 

Iatraleptic method (larpo?, surgeon, aAeipw, to anoint), the mode of medication by 

friction of medicines. 
Ichthyosis (ixflu?, a fish), the fish-skin disease, from the resemblance of the scales of the 

disease to those of a fish, 335. 
Idrosis, same as Hj'drosis. 
Impetigo (irnpeto to attack, or impctire to infest). It has been applied to very many 

different diseases in past times. It is now used as designating pustular eczema, 16o, 

S2i 
Impetigo contagiosa, 223. 
Impetigo rodens, 233 (footnote). 
Imflammatory products, 105. 
Intertrigo {inter between, tero to chafe), a chafe gall or fret. The excoriated surface 

produced by the friction of two surfaces of the skin, 108. 
Introduction, 1. 
Ionthos (from Zov0o; the root of the hair, allied to av6e£ to bloom, according to some, 

from lou violet, and av9o<; a flower). It was applied to the acne of the face that 

appears at puberty when the hair of the beard is forming. 
Iron, preparations of, see Formulae, Nos. 159, 161. 
Italian leprosy, 123. 

Itch, psora of the Greeks, scabies of the Latins, 417. 
" insect, the acarus scabiei, 4^0. 
" bakers', bricklayers', grocers', washerwomen's itch, see Lichen Agrius, 139. 

Jazam or Juzam, an Oriental term for leprosy, 310. 

Kelis, Keloid (k-^ a tumour, and eI£o? like). Others derive the words from xv^h a 
seabank or mole, or K17A1'?, a stain. By these terms are signified a hypertrophous 
growth of the fibrocellular tissue of the skin, 347. See also Ciieloid. 

Keloid of cicatrices. 34S. 

Kerion (K-npiov, a honeycomb), a form of vegetable parasitic disease allied to tinea tonsu- 
rans. The follicles are inflamed and pour out a viscid secretion, 445. 

Keratoses (*epas. /cepalos, a horn), 330. 

Kidney disorder, influence of, 10. 

Kidinga pepo, 103. 

Lentigo, Lexttcula (7 ens, lentis, a lentil), a freckle ; lentil-shaped macula? ; they are not 

seasonal like sunburn, 402. 
Leontiasis (Aeoi/nWi?, lion like), a term applied to the lion -like aspect of the face in 

tubercular leprosy, 310. 
Lepra (Aen-pa. leprosy, from Aen-po? scaly). A term applied at one time to true leprosy, 

but now to the scaly disease lepra vulgaris. See Psoriasis. 
Leprosy, 310. 

Leucasmus (Aev/co? white), the same as leucoclerma, a whitening of the skin from deficien- 
cy of pigment. 
Leuce (Aevx:6? white), lepra leuce, the white anaesthetic patch of true leprosy, 315. 
Leucoderma, 401. 
Leucopathia (Aev*6s and ttcWo? affection), pigment deficiency. It generally is applied to 

albinism. 
Lichen {\^xh v lichen, a true moss). The Greeks applied the plural lichenes to scaly 

diseases. Lichen is now used to signify one of the papular diseases, 138, 
Lichen planus, 144. 
" ruber, 144, 
" scrofulosum, 151. 
" tropicus, 484. 
" urticaria, 128. 
Liver disorder, influence of, 10. 
Liver-spot, a term applied to pigmentary stains or to chloasma, which is a parasitic 

disease. 
Linear atrophy, 365. 
Local dermal inflammations, 104. 
Lotions, see Formulae, 34 et seq. 



528 GLOSSARIAL INDEX. 

Lupus erythematodes of Germans, 378. 

" (Latin for a wolf), so called from the ulcerating or devouring character of the dis- 
ease. It is regarded as a scrofulous inflammation and ulceration, 369. 
Lymphatics, disorder of, in skin disease, 7. 

Maculje {macula a stain), a discoloration of the skin, mostly pigmentary, 27. 

" syphilitica?, 283. 
Madura foot, a synonym for fungus foot of India, common at Madura, 468. 
Maize, diseased, as a cause of disease, 130. 
Malignant pustule, 238. 
Malpighian layer, 15. 
Mamma yaws, 97. 
Medicinal rashes, 133. 

" " arsenic, 133. 

" " bromide of potassium, 134. 

" " copaiba, 135. • 

" " iodine, 133. 

" " belladonna, 135. 

" " sulphur, 136. 

Mercurial remedies, see Formulae Nos. 147 et seq., 174 et seq. 
Melanoderma (^e'Aas, /ue',Wo? black, Sep/jLa skin), black discoloration, 402. 
Melanopathia, same as the last, black disease, 9. 
Melas (/xt-Ai? black), the term applied to the black anaesthetic patch in true leprosy — i.e., 

lepra melas. 
Melasma (ixe\a<rixa a black spot), the same meaning as melanoderma, 402. 
Meliceris (^eVu honey, ktjpo? wax), the same as kerion. 
Melitagra (aypa. seizure), honey-like eruption, or eczema impetiginodes in some of its 

aspects. 
Mentagra (mentum chin, aypa seizure), a term applied to sycosis, 459. 
Mentagrophyton {<$>vtov a plant), parasitic sycosis, see Mentagra, 458. 
Mercury in syphilis, 306. 

Mercurial formula;, see Formula, 143, 150, and 175 to 179. 
Microsporon (Vx-po? little, cr-ropo? a seed), a generic term for certain vegetable parasitic 

fungi found in chloasma and alopecia areata. 
Microsporon Audouini, the fungus of tinea decalvans, 461. 

" furfur, the fungus of chloasma, 463. 

Miliaria {milium a millet seed), 483. 
Miliary fever, an eruption of spots the size of millet seeds, due to vesicles produced as 

the result of excessive perspiration. Sudamina is the same disease, 483. 
Molluscum (mollusciis, mollis, soft), small soft tumours produced by distension of the 

sebaceous glands by secretion, applied at one time to fibroma. The resemblance to 

molluscous animals is stated to have suggested the application of the term, 491. 
Molluscum contagiosum, 491. 
Morbilli {morbillus distemper), measles, 87. 
Mineral waters in skin diseases, see Formulary. 
Morphcea {/xop^ form), special diseases of the skin, in which a substance like hard wax 

is formed in the skin, 339. 
Morve, a synonym of glanders. 
Multiformitv of eruption, 8. 

Mycosis (,111^775 a fungus), a synonym of frambcesia or yaws ; so used by Alibert, 96. 
Mycetoma, the fungus foot of India, 468. 
Myringomycosis, 474. 
Myrmecia (/xv'p^f an ant), warts on the palms of the hands, or soles of the feet. 

ISLevus, a mark ; they are hairy, vascular, or pigmentary, 363. 
Kails, diseases of, 

" parasitic, 466. 

" structure of, 23. 
Neoplasma (i/e'o? new, nXacrixa formation), a new formation, 369. 
Nerve, disease originating in disorder of, 6. 
Neuroses of the skin, 395. 
Neurosis, nerve disorder, 6. 
Ngerengere, the leprosy of New Zealand, 317. 
Nigrities, Nigredo (niger black), darkness of the skin. 



GLOSSAEIAL INDEX. 529 

Noli me tangere (touch me not), lupus exedens. 

Noma (vofirj, from v'sp.^ to spread), a general term for sloughing ulcers. 

Norwegian scabies, 423. 

Nosophyta (voao? disease, Qvtov a plant), vegetable parasitic diseases, see Tinea. 

Occupation and disease, 61. 
Old, diseases of the, 9. 
(Estrus, 406. 

Ointments, see Formulary. 

Onychia (owt- the nail), inflammation of the nail, 466. 

Onychomycosis (bw^ a nail, ixvK-qs a fungus), parasitic disease of the nails, 466. 
Ophiasis (o^i'ao-is, from bcpis a serpent)*, serpentine. A bald place, in irregular band- 
like fcrm. 
Osmidrosis (607^ odour, and ZSpaxn? sweating), foetid perspiration, 480. 

Pachydermia (^ax^s thick, Se>/xa skin), a thickened state of skin, 358. 
Pachydermatocele (Pachydermia, which see, and ktjAtj tumour), hypertrophy of the skin 

forming a tumour, 358. 
Pachylosis (TraxvAo? thickish), the same as Pachydermia. 
Papillae (papula a pimple) of skin, structure of, 18. 

" of hair follicle, 20. 

Papula (a pimple), a solid elevation of the skin of minute size, 30. 

u varieties of, 30. Diagnostic features of different papuke, 63. 
Papular diseases, 137. 
lt syphilis, 284. 
Parasitic diseases, nature of, 405. 
" animal, 405. 

" vegetable, 425. t 

Parasites (see Fungi), 426. 

Paratrimma (ira.po.TpL$o> to rub together), see INTERTRIGO. 
Paronychia (-apa about, bw£, the nail). 
" whitlow, 499. 

" syphilitic, 295. 

Pathology, general remarks on, 27. 
Pediculus, the louse, 409. 
body, 412. 
" pubis, 411. 

11 head, 410. 

Pellagra (Italian, pelle skin, agra rough), Italian leprosy, 128. 
Pemphigus (-nip.^ a bladder or blister), one of the bullous diseases, 211. 
" its varieties, 211. 

" the bullae of, 32. 

" pruriginosus, 213, 220. 

" syphilitic, 288. 

Pernio (Tr-ipva. the heel), a chilblain, 108. 
Perspiration, alteration of, 475. 
Petechia (petecchie, Italian, a flea-bite), minute points of extravasated blood seen in 

purpura, 392. 
Phlyctsena (fykvuraivo. a vesicle), a general term for vesiculas and bladders. 
Phlyctenosis, an eruption of phlyctenae. 
Phlyzacion (4>kv£6.Keov, </>Au'£a>, to be hot), a pustule with a hard and inflamed base 

with a vivid red color, and succeeded by a hard, dark, thick scab. 
Phthiriasis (^fleipuxcn.?, from <j>9eip a louse), the lousy disease, or morbus pedicu- 

laris, 409. 
Phyma ($vp.a a tumour, or (Jvu to spring forth), a small boil. 
Phytoderma (<£utoi/ a plant, Sipixa skin), any vegetable parasite that grows on the skin, 

hence phytoderma, the diseases in which fungi occur. 
Pian (a raspberry), the same as frambcesia, 96. 
Pigment alterations, 399. 

Pityriasis (irirvpov bran), a branny or scaly disease, 331. 
" pilaris, 254. 
" rubra, 253. 

" " anomalous form of, 258. 

Plica polonica (plico to knit together), the Polish plait, a disease seen in Poland espe- 
cially, in which the hair is much matted together. 

34 



530 GLOSS AEIAL INDEX. 

Podelkoma, a synonym for the fungus foot of India, 468. 

Pomphi, wheals, see next. 

Pompholyx {noix4>6\vg a water buhble), the same disease as pemphigus. 

Porrigo, a term applied to so many different diseases that it should be at once discarded 
to avoid endless confusion. 

Porrigo scutulata, an old term for tinea tonsurans. 

Prickly heat, 484. 

Private practice, diseases seen in, 9. 

Prognosis, general, 65. 

Prurigo (pvurio to itch), a particularly itchy and rashy disease, 156. 

Pruritus (prurio to itch), itching, 396. 

Psora (v//topa the itch), scabies. The Greeks used the term to eczema. 

Psoriasis, literally an itching disease. Some apply the term to lepra vulgaris ; Mr. Wil- 
son to the scaly stage of chronic eczema, 259. 

Psydracia {^yhpamov, i//uSpa£ a blister on the tongue tip, from xjjvSpetv to lie, or \pvxp*. 
vSpdKia cold blisters). An inflammatory pustule, less deep and red than phlyzacious 
. pustules. 

Pterygium (irTepvyiov, a little wing), epidermis growing over the nail. 

Pulex irritans, 405. 
" penetrans, 405. 

Purpura {purpureus purple), the purple eruption caused by haemorrhage into the 
skin, 392. 

Purpura urticans, 119. 

Pustula or Pustule, an elevation of skin produced by a collection of pus, 36, 64. 

Pustula maligna, 238. 

Pustular diseases, 223. 
syphilis, 288. 

Pyogenic {™ov pus, yeVeo-is creation) pus producing. 

Radesyge. This, according to Boeck, is a bad form of syphilis. 
Rakta piti, an Indian name for leprosy, 310. 
Recurrent herpes, 285. 
Renal, deficient secretion, 71. 
Rete Malpighii, 14. 
" mucosum, 14. 
Rhagades (pa-yas a rent or chink), a scab, fissure or chap. 
Rheumatism, influence of, 71. 

Rbinoscleroma {piv the nose, o-KXrjpiaiia a hardness, from cncATjpb? hard), 345. 
Rodent ulcer (rodo to gnaw), a chronic ulcerating disease, the least expressed form of 

cancerous degeneration of the skin, 387. 
Root sheaths of hair, 20. 

Rosalia (rosa a rose), rose rash, an ally of scarlatina, 93. 
Roseola {rosercs rose-colored), an acute febrile disease, accompanied by the development 

of a rash of rosy hue, 114. 
Roseola syphilitica, 282. 

Rotheln, a German term for rubella, or false measles, 93. 
Rubella, a name given to a bastard form of measles by Dr. Veale, 93. 
Rubeola, {ruber red), measles, 87. 
Rupia (pi)™* dirt), a syphilitic crusting disease, 287. 

Sarcoptes, a synonym of the acarus scabiei, 420. 

Sarcocele, 359. 

Satyriasis (Sarvpo?, a satyr), a synonym of elephantiasis, from the fact that the counte- 
nance presents the aspect of a Satyr. 

Sauroderma (cravpos a Saurian reptile, Sep/xa skin), ichthyosis in which the plates or scales 
are like the outer covering of the Saurian reptiles. 

Scabies (scabere to scratch), the itch, 417. 
" "Norvegica, 423. 

Scabrities (scaber rough), thinness of the nails. 

Scales, 38. 

Scall (scala a scale), a term very variously applied ; it has no precise signification now-a- 
days. 

Scarlatina (scarlatto, Italian, a red-colored cloth). Scarlet fever, 87. 

Scars, 47. 



GLOSS AKIAL INDEX. 531 

Scinde boil, 247. 

Scleroderma (o-kAtjpos hard, Sipfia skin), a disease in which the skin hardens and indu- 
rates, 342. 

Scleroma and Scleriasis. The same as the last, 342. 

Scratching, effect of, 53. 

Scrofula, influence of, 72. 

Scrofuloderma, explains itself as scrofulous disease of the skin, 276. 

Scurvy, 393. 

Seat, primary of diseases, 4. 

Sebaceous glands, diseases of, 486 ; structure of, 21. 
" cysts, 491. 

Seborrhoea (sebum or sevum suet, and pew to flow), sebaceous flux, 486. 

Senile decay, 366. 

Shingles (cingulum a girdle), herpes zoster, 201. 

Sibbens (from siwin, Celtic for raspberry, or sivvens wild rash), framboesia. 

Skin diseases, how to study, 2. 
14 structure of, 14-24. 

Soaps (see Formulary). 

Spargosis (o-Tripywo-t? swelling). The same disease as bucnemia tropica, 358. 

Spedalskhed, a Norwegian term for true leprosy or elephantiasis Graecorum. 

Spilus (crn-rAos a spot), a mole or pigmentary naevus. 

Spindle-shaped cells in skin, 16, 18. 

Squamae, 38. 

Squamous Diseases, 252. 

Stages, significance of, in diseases, 2. 

Stearrbcea (a-reap fat, pew to flow), the same as seborrhoea, excessive sebaceous secre- 
tion, 486. 

Steatoma (cniap fat), a fatty tumour. 

Steatozoon (£u>ov animal), the animalcule found in the sebaceous ducts, 490. 

Stimulant remedies (see Formulae). 

Stomach, influence of disorders of, 10. 

Strophulus (a-Tp6(j)os a twisted band), ordinarily described as the lichen of children. It 
is the " red gum," "red gown," 153. 

Strophulus, varieties of, 154. 

Strumous diathesis, and skin diseases, 11. 
" diseases, 276. 

Sty (stihan, Saxon springing up), a small boil, formed by one of the suppurating Meibo- 
mian glands of the eyelids, 231. 

Subcutaneous cellular tissue, structure of, 19. 

Sudamina (sudo, to sweat), a vesicular eruption, the result of excessive sweating, the same 
as miliaria, 483. 

Sulphur rash, 136. 

Sweat glands, structure of, 22 ; diseases of, 475. 

Swine-pox, 84. 

Sycosis (o-uKwcris a rough or fig-like excrescence), inflammation of the sebaceous follicles of 
the beard, 502. 

Syphilodermata (o-t^Aos defect, Sep/xa skin), syphilitic skin eruptions, 277. 

Syphilitic acne, 289; alopecia, 294; eruptions, general characters of, 280 ; dactylitis, 
297 ; ecthyma, 289 : exostosis, 296 ; herpes, 2S5 ; lichen, 284 ; maculae, 283 ; 
onychia, 295 ; pemphigus, 287 ; roseola, 280 ; scaly, 290 ; tubercle, 291 ; ulcers, 294. 

Tar acne, 133. 

Teleangeiectasis (Te'Aeio? complete, dyyelov a vessel, e/cTaai? extension), tumour formed 

by an excessive growth of vessels. 
Temperament, effect of, 61. 
Terminthus (repijuvdog or repej3iv0o?, the turpentine tree), a carbuncle in shape and size 

like the ripe core of the turpentine tree. 
Tetter, of uncertain application, analogous to the word dartre. 
Therapeutics, general principles of, 66. 

Tinea (a moth or woodworm), the generic term for vegetable parasitic diseases, 324. 
Tinea favosa, 429; its fungus, 430; tonsurans, 432; its fungus, 433 ; circinata, 447 ; 

sycosis, 457 ; its fungus, 458 ; decalvans, 460 ; its fungus, 461 ; versicolor, 462 ; 

its fungus, 463 ; kerion, 445. 



532 GLOSS ARIAL INDEX. 

Tissue changes, 5. 

Treatment, general principles of, 6G. 

Trichinosis (k>cto? disease), disease of the hair. 

Trichogenous (0pi£ the hair, yiwaio to generate), hair producing. 

Trichomyces (0pi£, rpixos hair, p.u«rj S a f angus), any parasite of the hair. 

Trichophyton {fyvrbv a plant), a vegetable parasite of the hair. 

" tonsurans, 433. 

Tubboes, 98. 
Tubercula {tuber a swelling), the plural of tuberculum, signifying a small swelling. 

Tubercula is applied to the group of diseases including cancer, lupus, fibroma, which 

commence by small indurations, 40, 64. 
Tubercular leprosy, 311. 

syphilids, 291. 
Tylosis (nAoo-is, t-J/Voj, a knot), callus, callosity, 333. 
Typhoid fever, eruptions in, 87. 
Typhus " " 86. 

Ulceration, 46. 

Uniformity of eruption, 8. 

Urticaria (urtica a nettle), nettle-rash, 116; in children, 124; papulosa, 124. 

Uterine disorders, influence of, 10. 

Vaccination, 84. 

" eruptions following, 85. 

Vaccinia {vacca a cow), cow-pox, 84. 

Varicella (varicula, dim. of varus, a pimple), chicken-pox, 84. 
Variola (varius spotted), description of, 80; disfigurements after, S3; modified, 83 ; 

verrucosa, S3. 
Varioliform syphilis, 2S6. 
Varioloid, 83. 

Varus (uneven), a rash on the face, especially acne. 
Vascular supply, alteration of, oGo. 
Verruca, a wart, 333. 

" necrogenica, 334. 
Vesicles {see next), 32, 64. 

Vesiculse {vesica, a bladder), small bladders, a vesicle, 32. 
Vesicular disease, 32. 

" syphilis, 285. 

Vessels, blood, alteration of, 363. 
Vi bices {vibex, a wheal), large petechias. 
Vitiligo (litium, a blemish). The term is used very differently, some meaning thereby 

leucoderma, others the white scars left after ulcerative disease. 
Vitiligoidea (vitiligo, 2i5o?), a ganeral term, meant to designate a yellow discoloration 

under the eyelids {see Xanthelasma). 

Wheals, nature of, 29. 

Xanthelasma {£av66<;, yellow, i\aaixa, lamina), yellow hypertrophy of the epithelial 

lining of the sebaceous ducts, 488. 
Xanthoderma, yellow skin, 403. 
Xeroderma (f»jpbs dry, Sep.aa), a disease characterized by dryness and scaliness of the 

skin, 335. 

Yaws (a raspberry, Afric), framboesia, 95. 

Zittman treatment, 308. 

Zona {tJjv-q a belt), herpes zoster, 201. 

Zoster {^j-t'yjo a belt), herpes zoster, shingles, 201. 

" syphilitic, 285. 
Zymotic (£6.u.y), leaven) acute contagious diseases, supposed to be due to the action of 
animal ferments or viruses. 

THE END. 









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